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Scopolamine - Morphine 
Anaesthesia 



BY 



BERTHA VAN HOOSEN, M.A., M.D. 

Attending Gynaecologist to 

Cook County Hospital, Provident Hospital and 

Mary Thompson Hospital. 

Member of 

The American Medical Association, 

Illinois State Medical Society, 

Chicago Medical Society, Etc. 



AND 



A Psychological Study of " Twilight Sleep " 
Made by the Giessen Method 



ELISABETH ROSS SHAW 

Consulting Psychologist 



THE HOUSE OF MANZ 

CHICAGO 








Copyright 1915 by Bertha Van Hoosen, M. D. 



Published February, 1915 

Printed in United States of America 

By 
Manz Engraving Company, Chicago 



FEB II 1315 



A393592 



CONTENTS 



PAGE 

Preface 9 

Chapter I 
Introduction 15 

Chapter II 
Pharmacology, Toxicology and Physiological Action 19 

Chapter III 
Administration for Surgical Anaesthesia 29 

Chapter IV 
Administration for Obstetrical Anaesthesia 39 

Chapter V 
Typical and Atypical Cases 43 

Chapter VI 
Report of 5,000 Morphine-Scopolamine Anaesthesiae 55 

Chapter VII 
Report of 100 Consecutive Cases of "Twilight Sleep" at the Mary Thomp- 
son Hospital, from June 1 to December 1, 1914 85 

Chapter VIII 
The Mental Effects of "Twilight Sleep" by Elisabeth Ross Shaw 103 

Chapter IX 
Bibliography Compiled from the Crerar Library 185 



ILLUSTRATIONS 

FACING 
PAGE 

'* Frontispiece — Alice Amelia Hagerman, born June 3, 1914. 

v Plate I— Sectional Delivery Bed {Closed) 32 

- Plate II — Sectional Delivery Bed (Open) 32 

^ Plate III— Bed with Screen Adjusted 40 

* Plate IV— Bed with Canvas Partially Adjusted 40 

^ Plate V — Bed with Canvas Adjusted Forming a Crib 48 

v Plate VI — Patient in Crib Bed Ready for Examination 48 

* Plate VII — Bed Disjointed and Preparation for Delivery 64 

" Plate VIII — Preparations for Delivery Complete Except Sterile Covers... 64 
-Plate IX — Sterile Covers and Gyn. Sheet Applied 72 

* Plate X — Obstetric Envelope Opened 72 

* Plate XI — Obstetric Envelope (Front View) 80 

v Plate XII — Obstetric Envelope (Back View) 80 

- Plate XIII — Gown with Continuous Sleeve 88 

Plate XIV — Gown with Continuous Sleeve Behind Neck 88 

Plate XV — Van Hoosen Method of Deepening Respiration or Awakening 

Patient 96 



TO MY SISTER 



mm 



PREFACE 

T the Tri-State Medical Society, which was held 
at Des Moines, October 13 and 14, 1914, I 
read a paper the content of which is embodied 
in this little book. It provoked much discussion 
and was adversely criticized by many physicians who had 
had no personal experience in the use of this anaesthesia. On 
the following Sunday the Des Moines "Register and 
Leader" gave a full report of the paper and discussion. 
This was criticized by Dr. Hutchins of Des Moines on the 
following day. In reply, Dr. Arthur J. Booker wrote the 
following : 

"It is less from a desire to enter a controversy than to 
come to the rescue of my friend, Dr. Bertha Van Hoosen, 
that I reply in this manner to the genial, and in some re- 
spects, so far as 'twilight sleep' is concerned, correct Dr. 
Hutchins. 

"Those who think Dr. Van Hoosen's enthusiasm over 
morphine and scopolamine to have begun with McClure's 
magazine are all amiss. Eight years ago I had the oppor- 
tunity as an interne to see the doctor use this method for 
a year and a half. About three years ago she used it here 
in a big clinic, with excellent result, as characterizes her 
work. She is one of the many competent surgeons to stick 



R 



by this method and prove its worth, as is necessary with any 
new proposition. 

"This method of anaesthesia is based upon sound surgical 
principles, which have been made very definite, by no less 
eminent surgeon and philosopher than Dr. George Crile 
of Cleveland, who is the world authority upon anoci- 
association. It has the indorsement of Bloodgood and a 
coterie of men who are lights in surgery. As Dr. Hutchins 
well stated, it has been used for years by men who pretend 
to keep up with advances in medicine, and no fuss was made 
about it. 'Twilight babies* have been born all over the 
country for years and nothing was said about it, because 
most men are more concerned to meet conditions and get 
results than to deal with names. 

"Now let us make a brief analysis: If this anaesthetic is 
a good thing in a large clinic such as Crile has, as Bloodgood 
is furnished with, and we will say, for sake of argument, as 
Dr. Van Hoosen claims — leaving out other examples — what 
is the objection to its use in obstetrics? Some men lay great 
stress on the occasional asphyxiated babies; but the most 
hostile critics do not claim that these same babies do not 
grow up to make third grade. After any anaesthetic, used 
for a period long enough to make the mother unconscious, 
we expect more or less asphyxia. Every well equipped 
obstetric bag is furnished to meet this condition, even by 

10 



R 



men who do not use this method, and before it was used. 
No one has discovered that a little asphyxia hurt the child. 

"Whether it be ether, chloroform, scopolamine or any one 
of the various anaesthetics which is used, nothing is going 
to take the place of brains and judgment on the part of 
physicians. There are idiosyncrasies and contra-indications 
to nearly every drug we know and no anaesthetic is admin- 
istered without serious thought on the part of the attendant. 

"Dr. Van Hoosen needed no popular article to make her 
enthusiastic about a method she has used with striking suc- 
cess for ten years, as her pupils and those who attended her 
clinic can attest. Quite the contrary to Dr. Hutchins' belief, 
scopolamine was never so popular as today. It is not a 
depressant to the circulatory apparatus; quite to the con- 
trary, it seems to stimulate the heart by its action on the 
vagus nerve. Men who give much choloroform or ether 
after the administration of scopolamine clearly prove that 
they do not understand the principles. It does not irritate 
the kidneys as do some other anaesthetics, as may be proven 
by laboratory analysis. As for the milk, this is stimulated to 
flow because the mother has not been so exhausted and the 
flow of blood to the glands is better and the stimulation of 
nursing causes a better secretion as a result. If we depended 
on the Almighty to look after the milk entirely all the babies 
would be better off. 

11 



PREFACE 

"The depressing effect of this anaesthetic is almost nil, 
even when given in the full amount, as there is no time when 
the patient cannot be aroused; after the advent of labor 
the mother is usually in a refreshed condition. 

"Dr. Van Hoosen did not take her own cases covering 
a period of years as the basis of her paper, but the last 
fifty cases in the Mary Thompson Hospital — where this 
anaesthetic is used — and the last fifty at the County Hospital, 
where it is not used. Her comparisons were rather those 
of a disinterested party than of an enthusiast. Her 
conclusions were fair. She thinks it is excellent, as do 
thousands of other physicians throughout the country; but 
in the final analysis it is a question for the attending man 
and not the patient to decide. 

"If the mothers live and the children do not die — and 
the most virulent critics admit this — it does not matter if 
the baby does not keep the neighbors awake the first night. 

"It took a queen to make chloroform popular; and since 
we have no queens in this country perhaps it depends upon 
the women physicians and the mothers to exercise their 
sovereignty." 

At the request of friends like Dr. Booker, and to fortify 
my position before my critics, I have been led to write my 
views and my experience with the anaesthetic so recently 
christened "Twilight Sleep. ,, 

12 



PREFACE 

I am indebted to Dr. Anna Handshaw and Dr. Josephine 
McCollum for statistics and collateral reading. Dr. 
McCollum has been special anaesthetist to Mary Thomp- 
son Hospital for many years and was the first to administer 
it in the Gynaecological Clinic in the Illinois State Medical 
School. Dr. Handshaw administered it in the same clinic 
for a period of eight years. She also wrote the chapter on 
"Pharmacology, Toxicology and Physiological Action." 
Both have given valuable suggestions and opinions for 
other chapters. 

Drs. McCollum and Handshaw were experts in chloro- 
form and ether anaesthesia before giving any attention to 
scopolamine-morphine anaesthesia. 

Dr. Pearlie Mae Stettler has compiled the Bibliography 
and Drs. Mulcahy, Ackerman and Gardner have given 
valuable assistance in developing the present method of 
Twilight Sleep Delivery at the Mary Thompson Hospital 
during their obstetric service. 

Dr. Maud Ethridge, Miss Jane Parmlee and Miss 
Clara Stuart have contributed many hours' work in collect- 
ing records. 

The 5,000 cases reported include nearly all of my 
operations during the past ten years, with operations by 
Drs. Mary Gilruth McEwen, Mary Jeanette Kearsley, 
Clara Ferguson, Bertha Bush and Nora Johnson. 

13 



R 



Without the assistance of these women it would have 
been impossible to produce this report. I take this 
opportunity of expressing my appreciation of their work. 

Bertha Van Hoosen. 
32 North State Street, Chicago. 



14 



Scopolamine- Morphine Anaesthesia 

CHAPTER I 

Introduction 

JN the Fall of 1904 I saw Dr. Emil Ries of 
Eft Chicago use scopolamine-morphine anaesthesia in 
■faffi his clinic. It was the first time that I had ever 
seen a patient under any anaesthesia except 
chloroform, ether or gas. I was then using continuous 
gas anaesthesia with great success, but the enormous expense 
attached to the gas anaesthesia, together with the necessity 
of having for an assistant a person who was not only 
trained to administer it, but who was also of an alert and 
self-reliant disposition, made me ever ready to take up 
something more practical as soon as it could be found. 

No novice at a spiritualistic seance could have been more 
deeply impressed than I was at that first clinic. I felt as 
deeply impressed as though I had never seen a patient under 
any anaesthetic. Natural sleep, death, hypnosis, catalepsy 
and intoxication all seemed to be blended into a composite 
making up the wonderful "Twilight Sleep." 

One of my little patients — a girl of fourteen, who had 
nearly lost her life under a short choloroform anaesthesia 
given simply for an examination, and on this account was 



15 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

dreading an operation for recurrent appendicitis — had asked 
me if there was any anaesthetic "where the mind would go 
to sleep first and wake up last?" This was a description of 
scopolamine-morphine anaesthesia, and under its refresh- 
ing sleep this young girl went safely through her operation. 
At the time that I first saw this anaesthesia used I was 
occupying a clinical chair in the College of Physicians and 
Surgeons. My clinics were in the college amphitheatre and 
the patients were cared for at the West Side Hospital, which 
was connected with the college building by a bridge over the 
adjacent alley. At the end of the first year of my professor- 
ship the West Side Hospital authorities refused to admit my 
patients, and I was forced to improvise a hospital from a 
store and an adjoining flat just across the street from the 
hospital. The strain on clinic patients is always great and 
immeasurably so when they must be transported in all kinds 
of weather across a noisy street and up a college elevator to 
a college amphitheatre. It was to relieve this strain that 
I introduced scopolamine-morphine anaesthesia as routine 
for all my surgical patients in my clinic. This clinic was held 
on Saturdays from 8:00 to 10:00 a. m., and every patient 
who was to be operated on that day received an injection 
of scopolamine-morphine at 5:30, 6:30 and at 7:30 o'clock 
and at 8 :00 were so deeply asleep that the ride in the 
ambulance to and from the college, the examination by 

16 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

the students, the operation and everything that happened 
from two to six hours after the operation were all a blank. 
For the first three months I was forced to give the hypo- 
dermic injections myself because of the fear the nurses 
held for the drug. 

To do this I arose at 4:00 a. m. and traveled ten miles 
to administer the first dose at 5 :30. It was not long, 
however, before our nurses were quite enthusiastic and 
willing to undertake the administration of the injections. 

I also began at that time to use it in all my private 
operations at the Woman's Hospital. But here also, on 
account of the prejudice of the superintendent of nurses, 
the nurses were not allowed to give the hypodermic injec- 
tions, and they were given by the internes. It was about 
this time — in 1906 — that the Board of Women Managers 
of the Frances Willard Hospital refused to allow me to 
use scopolamine-morphine in their hospital and I received 
a letter from the President of the Board to that effect. 

Other hospitals, though they did not actually refuse, 
showed such disapproval of my anaesthetic that its admin- 
istration was made very burdensome to me. 

I know of no other instance where nurses were not 
allowed to carry out a doctor's orders or where lay 
members of a board of trustees ventured to criticize a 
surgeon's choice of an anaesthetic. 

17 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

One of the most encouraging things has been that the 
internes in the hospitals where I have worked and the 
physicians on whose patients I have operated have never 
had anything but praise, confidence and admiration for 
this anaesthetic. I have operated upon twenty-eight women 
physicians and more than one hundred nuns under this 
anaesthetic, and no one of them ever hinted a fear of it. 
Six years ago I had the pleasure of demonstrating 
scopolamine-morphine to Dr. Mary Smith of Boston, from 
whom I received my first instruction in surgical technique. 
She at once introduced it at the New England Hospital 
for Women and Children, where it has since been in use. 
Many of my students have reported its satisfactory use in 
the foreign field where assistants were scarce and chloro- 
form and ether difficult to transport. 

More than fifty nurses have had operations under this 
anaesthetic, for it is, after all, the nurse who most appre- 
ciates its advantages. 

Scopolamine-morphine anaesthesia converts the day of 
operation from an anxious, disagreeable day to the quiet- 
est day in the hospital. 



18 




CHAPTER II 

Pharmacology, Toxicology and Physiological 
Action of Scopolamine-Morphine 

COPOLA was obtained in 1889 by Banger and 
again in 1890 by Dr. Schmidt, who named the 
plant Scopola for his friend, Dr. John Scopoli, 
of the University of Pavia. 

It is a dried rhizome of Carnolacea Jacquin, of the 
family Solanacea, a perennial plant of horizontal growth 
about a foot high, distinguished botanically by its fruit 
being a transversely dehiscent capsule, thinner leaves than 
belladonna — which it resembles — and is also distinctly 
rhizome, the roots lying above the ground and sending 
their tendrils downward into the earth. It exhibits a 
yellowish-white bark, its corky layer dark brown or pale 
brown; its wood is distinctly radiate and central pith 
rather horny; nearly inodorous, taste sweetish at first, then 
after taste bitterish and strongly acrid. The plant is 
common in Bavaria, Austria-Hungary, South Russia and 
Northern United States. 

Scopola contains an alkaloid named scopolamine called 
a natural amine N 3 base. Most alkaloids occur naturally 
as nitrogen bases. Where the N 2 or N 3 is found as a 
nitrogen base the name is amine. Hence Scopola is called 
an amine. Scopolamine hydrobromide has chemical form- 

19 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

ula C 17 H 21 N0 4 H 2 Br, and it contains also a hydroiodide 
and hydrochloride, as well as apoatropine. Scopolamine 
is levarotary, deviating the plane of polarization to the 
left; has an optical rotation varying from twenty degrees 
to as low as two degrees, has the independent atroscin 
(and an impurity apoatropine), to which is due its physi- 
ological identity and much of its therapeutic action. Of 
the fluid extract of scopolamine evaporated, dose is 
grains % to y 2 ; percolated with alcohol 8, water 2, dose 
is y 2 to 1 grain. Extract of scopolamine (United States 
Pharmacopoeia) contains two per cent of mydriatic alka- 
loid; dose of fluid extract m*^ to 3 contains 0.5 g. m. 
of mydriatic alkaloid and is now officinal in the eighth 
edition of the United States Pharmacopoeia of 1905. 
Scopolamine appears in the form of prismatic crystals 
fusing at 138° F. (58° C), soluble in water, alcohol and 
ether. 

It degenerates rapidly when exposed to the air or light, 
and should therefore be used in fresh solutions; it is best 
administered hypodermatically. 

Scopolamine with its chemistry is a most interesting 
study. Dr. J. W. Hassler, of New York, in an article 
of 1906 entitled "Why Scopolamine ?" gives the experience 
of a chemist of a leading New York house, who told the 
doctor of examining six specimens of scopolamine produced 

20 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

by six firms respectively. The analyses showed a variation 
in' strength of each specimen due to the presence of a 
greater or less degree of atropine, atroscin and apoatropine 
— arriving at the following conclusion: Commercial 
scopolamine is unfit for use as an anaesthetic. 

Merck has prepared a tablet grains 1/100 which is 
uniform in strength and in alkaloidal purity. 

Scopolamine could not be discussed without a reference 
to its companion and understudy, hyoscine and bella- 
donna?, which are also of the Solanacea. Hyoscyamus as 
a synonym, because by some workers it has been thought 
to be isomeric, has caused so much of confusion and lack 
of scientific acceptance of scopolamine that I have searched 
most diligently to differentiate it from hyoscine. The Hen- 
bane is a very different plant, and according to Ladenburg 
has not an isometric identity, as its chemical formula is 
C 17 H 23 N 3 Br — which gives a different chemical compo- 
sition. Hyoscyamus niger has a uniform optical radiation 
of minimum twenty degrees and is dextra rotary. Then, 
too, hyoscyamus is non-crystalline and is of a sirupy con- 
sistency, while scopolamine is crystalline. We can see that 
even macroscopically the two substances differ from each 
other. Notably enough, these most marked basic distinc- 
tions provide, when assayed as directed, the above per- 
centage of the pure' alkaloid as quoted and the purity of 

21 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

scopolamine can be tested. A drop of potassium per- 
manganate is added to the solution to be tested. If 
scopolamine with atropine alone are present no change 
occurs; if apoatropine, as much as 1/20,000 is present, 
a brownish-yellow color is produced by the formation of 
oxide of manganese. 

The German Pharmacopoeia uses scopolamine as officinal. 
The British Pharmacopoeia uses it as a synonym for 
hyoscyamus. The United States Pharmacopoeia uses 
scopolamine distinct from hyoscin and as officinal. Then 
the great difference between scopolamine and hyoscin is 
in its therapeutic and physiological activities, the latter 
provoking the phenomenon of intoxication, while the 
former does not. 

In Waugh- Abbott we find the following: 
"It is well to remember that all those authors who 
propose this identity of the two drugs speak of the 
hyoscin of commerce — that is, German hyoscin." Now 
our readers well know from numerous previous proofs that 
an alkaloid pure, and chemically definite, is far from a 
product delivered by German commerce under the name 
of an alkaloid. We do know from our earliest lessons in 
chemistry that the diamond is nearly pure carbon and that 
charcoal is also nearly pure carbon — the diamond is 
alliotropic with carbon and chemical* formula identical — 

22 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

but we do not quote them as being the same; why should 
we think of these two alkaloids, scopolamine and hyoscy- 
amus, as being the same?" 

PHYSIOLOGICAL ACTION 



SCOPOLAMINE 




MORPHINE 


Antagonistic Action 


Synergistic Action 


Antagonistic Action 


Elevates temperature. . . . 




Lowers temperature. 






Quickens respiration 




Slows respiration. 






Increases urinary secre- 
tion 




Slightly diminishes urin- 
ary secretion. 








Increases peristalsis 




Diminishes peristalsis. 






Arrests skin and salivary 
gland secretion 




Sudorific. 








Dilates pupil 




Contracts pupil. 






Raises blood pressure.. . . 




No effect on blood press- 
ure. 






Stimulates vaso motor 
centers 




No effect on vaso motor 
centers. 








Increases rapidity and 
force of circulation .... 




No effect on circulation. 








Excites motor areas of 
spinal cord . 




Depresses motor areas 
of spinal cord. 








Relieves pain. 










Induces sleep. 









23 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Therapeutics: Scopolamine is indicated wherever a 
mydriatic, antispasmodic, somnifacient, analgesic, hypnotic, 
narcotic, anodyne, anticonvulsant, or where a general 
anaesthetic is needed. 

Its first field of usefulness was that of the ophthalmolo- 
gist, as early as 1895. As a collyrium of 0.2 per cent its 
mydriatic effect upon the ciliary muscle is evidenced by 
the widely dilated pupil seen within two minutes after the 
drug has been instilled into the conjunctiva. The duration 
of its action is about the same as atropine, paralyzing 
accommodation for a few days. 

Dr. Schneiderlin, an alienist, used scopolamine in 1900 
to produce sleep in the restless insane and afterward suc- 
cessfully combined it with morphine to produce surgical 
anaesthesia for operative work upon demented patients, as 
it helped to allay motor activity. 

In 1901 Steinbuchel first used the drug in obstetrics and 
from it gained much assistance. These first years of its 
usefulness were confined to Europe. Its clinical use in the 
University Women's Hospital of Freiburg by Drs. Kroenig 
and Gauss is well known to all physicians. 

From 1904 to 1906 it began its interesting career in 
America with a growing number of adherents and enemies 
throughout the United States, every one of these adding 
an interesting chapter to its history. 

24 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Morphine sulphat synergist with scopolamine seems to 
be the best adapted to surgical anaesthesia. The patient 
sleeps but cannot always be kept sufficiently quiet for oper- 
ative purposes without novocain, chloroform or ether. 

Toxicology : 

The lethal dose of morphine is known to all; the lethal 
dose of scopolamine is not known. Two grains were given 
by Dr. Bryant in a test case, in three doses of two-thirds 
grain each, an hour apart, and he says that although he 
had interesting symptoms, the dose was not fatal. 

Kochman gave 30 grains intravenously to a 15-pound 
dog without fatal results. 

Scopolamine-morphine anaesthesia has great advantages — 
both ante- and post-operative — to the patient, the surgeon, 
the anaesthetist and the nurse. 

If the degree of anaesthesia at the time of operation is 
insufficient, use chloroform or ether in small quantities as 
an adjuvant. 

Though the pupil is no guide in scopolamine-morphine 
surgical anaesthesia, there are other and as definite and 
safe ones to be kept under the observation of the anaes- 
thetist: Watch the face for its danger signals of pallor 
or cyanosis, the respiratory excursion of the thorax and 
abdomen for any change. Keep your finger on the pulse 
(facial or radial artery). 

25 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

When asked what is to be done if trouble arises from 
the anaesthetic, I should say something was done when 
you gave the hypodermic injections, as the drugs scopola- 
mine and morphine are antagonistic and antidotal, and 
very little is left to be done. 

For cyanosis, flex the head on the chest to induce deep 
breathing, and give oxygen. If respirations are slow, or 
rapid and shallow, give oxygen. 

For a small, weak, rapid pulse, give hypodermoclysis, 
strychnine, alcohol or digitalin hypodermatically. 

There are certain diseased conditions of the patient 
which if present should make the watching more keen on 
the part of the anaesthetist. Watch carefully a patient 
with incipient tuberculosis; the second stage of tuberculosis 
is a call for a double watch, and little morphine should be 
given. 

In none of the degenerative diseases of the renal organs 
should an anaesthetic be given, including scopolamine-mor- 
phine. 

Functional diseases of the heart do not preclude scopola- 
mine-morphine anaesthesia. Organic diseases of the heart 
may, although we have had many with organic heart dis- 
eases take the anaesthetic successfully. 

If the patient has suffered from either sepsis or hemor- 
rhage, there will probably be more need of care, such as 

26 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

hypodermoclysis and heart stimulants during the operation 
to save the strength of the patient, or extra post-operative 
care. 

These precautions apply no more to this anaesthetic, how- 
ever, than to all others. 

In any surgical operation scopolamine-morphine is the 
anaesthetic of selection because it shortens duration of admin- 
istration and amount of chloroform or ether and so prevents 
cell death. Dr. Crile tells us that this and anoci prevent 
shock. 

The great number hostile to scopolamine is impressive — 
first, because when asked what they think of it they will 
tell you they do not use it, as it is dangerous; second, because 
some one else who has not used it says it is dangerous; 
third, if they have used it they seemingly had no method, 
and if they met with danger signals, abandoned its use as 
unsafe. I believe, with several of its adherents, that the 
burden of the proof of its efficiency, safety and future 
usefulness lies with its exponents — not its opponents — and 
these 5,000 cases surely are one of the weights of the 
burden of proof. 

Chloroform — the most perfect of anaesthetics for gen- 
eral inhalation and one of the most safe — has its enemies 
and had its struggle upward through the light; and it has 
its limitations. Some individuals should never be given 

27 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

chloroform. Some individuals (however trained) should 
never give chloroform. The same moralizing applies to 
the same extent, though for different reasons, to ether. 
The profession does not condemn chloroform and ether in 
toto; but their limitations lead us to search for another 
and better anaesthetic, and we have found it in scopolamine- 
morphine. 

To the chemist of the future we must look not for the 
commercial scopolamine, but for the special preparation 
that shall excel for purity and strength, so that when we 
purchase scopolamine hydrobromide we shall not have 
either apoatropine or atroscine to reckon with. Then it 
will be the anaesthetic of our dreams, made perfect 
through our struggles for efficiency. 



28 




CHAPTER III 

Administration for Surgical Anaesthesia 

N my early work with scopolamine-morphine 
anaesthesia I followed the technique laid down 
by Dr. Emil Ries. I gave morphine y 2 grain 
and scopolamine 1/50 grain in three equally 
divided doses: first dose given hypodermatically two 
and one-half hours before operation, second dose one and 
one-half hours before operation, third dose one-half hour 
before operation. I used this dosage for two years, when 
through a mistake of an interne — in miscalculating that 
1 minim equaled 1 drop — I found that I had been un- 
knowingly giving morphine «}4 grain and scopolamine 
3/100 grain in three equally divided doses to each patient 
for at least two months; it had brought no harm to the 
patients and was much more satisfactory than the smaller 
dosage. This dosage I have continued to use for the past 
seven years. 

In the importance of having a clear alimentary tract, 
of having the mind of the patient calm and free from 
worry, and a room that is quiet for the administration of 
the anaesthesia, this anaesthetic is similar to all others. 
Where we used the small doses (morphine 1/6 and 
scopolamine 1/150 repeated three times one hour apart), 
we were obliged to use chloroform, ether or gas as an 

29 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

adjuvant in ninety per cent of the cases. The amount of 
the adjuvant depended upon the nervous condition of the 
patient, the character of the operation and the familiarity 
of the anaesthetist and operator with the details of the 
anaesthesia. 

With the larger doses (1/100 scopolamine and *4 
morphine repeated three times one hour apart) , from sixty 
per cent to seventy-five per cent needed no adjuvant to 
deepen the anaesthesia for minor operations. The excep- 
tions hemorrhoidectomy and perineorrhaphy. In major 
operations twenty-five to forty per cent needed no adjuvant. 

We have given prolonged trials to ether, gas and chloro- 
form as adjuvants to scopolamine-morphine anaesthesia, 
and both Dr. Handshaw and I prefer chloroform, while 
ether is Dr. McCollum's favorite. 

Gas is not practical, because a skilled anaesthetist and 
a special expensive apparatus is necessary for its adminis- 
tration. Then, too, even a little carbondioxide increase 
in the blood is highly undesirable in scopolamine-morphine 
anaesthesia, because if any unusual complication or cause 
for anxiety arises it will come from a slowed respiration 
or a tendency to cyanosis. At St. Luke's Hospital, Chi- 
cago, where an expert anaesthetist and a special apparatus 
for giving gas and oyxgen are always at hand and where 
the patients receive the scopolamine under most favorable 

30 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

conditions in a private room with darkened windows and 
entire absence of noise, the administration of gas has been 
highly satisfactory; but these conditions are so rarely 
obtainable in routine work that gas is not advised as an 
adjuvant. 

The chloroform has many advantages; it does not irri- 
tate or congest the respiratory passages (as does ether), 
and patients do not resist its initial administration as they 
do that of ether; it is used in much smaller amounts and 
with greater admixture of air; its action is more rapid, 
there is less chance of irritating the kidneys and slightly 
smaller percentage of post-operative vomiting. It must be 
remembered that chloroform as an adjuvant is not admin- 
istered as chloroform is administered when given alone, 
but intermittently more in the manner of an obstetric anaes- 
thetic. When the operator and the anaesthetist work 
harmoniously together the anaesthetist will know when the 
operator is going to make such manipulations that a little 
chloroform will be required and will have given that small 
amount at the right moment and at other times when the 
manipulations do not disturb the patient she will allow her 
to sleep without administering chloroform. 

Very few patients do not resent the initial administration 
of ether, even though apparently deeply under the influence 
of morphine-scopolamine. So if it is thought best to give 

31 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

ether instead of chloroform as an adjuvant, it is wise to 
give enough ether to put the patient to sleep before 
adjusting the sterile sheets, and to continue to give it in 
exceedingly small amounts during the operation. Letting 
the patient come out of the ether anaesthesia will necessitate 
another rebellion on the part of the patient and possibly 
at a critical point in the operation. 

During the past year all of our operations have been 
done under local anaesthesia (the anoci of Crile) combined 
with the morphine-scopolamine anaesthesia. This combina- 
tion gives perfect results. 

In eighty per cent of major operations and in ninety-five 
per cent of minor operations no ether or chloroform will 
be needed. With it we have greater freedom from post- 
operative pain and vomiting. Patient after patient, when 
ready to leave the hospital, is asked, "Have you had any 
pain since your operation?" and the answer is invariably, 
"No"; or, "None to speak of." 

Morphine-scopolamine is most successfully administered 
in the early morning while the patient is still sleepy. With 
nervous patients I have found it most satisfactory to have 
the patient spend the evening preceding the operation at 
the theatre; the nurse may finish the preparation on the 
return of the patient from the theatre. 

Rules for a successful anaesthesia : 



32 




Plate I. Sectional Delivery Bed. {Closed.) 




Plate II. Sectional Delivery Bed. {Open.) 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

1. Nothing should be done in the way of preparation 
after the first dose is given. 

2. The patient must not be seen or spoken to by friends 
or questioned by nurses or doctors after the first dose. 

3. Make the patient's mind as free from anxiety and 
worry as possible. If she wishes to remain awake to speak 
with some one and it is not possible to arrange this, refuse 
positively so that she will not fight the sleep sensations to 
accomplish her desire. 

4. Draw the shades, make the patient comfortable and 
leave her alone in her room for at least one-half hour 
after the first dose. 

5. Take to the operating room on a cart and do not 
allow or ask the patient — even though apparently awake — 
to make any effort toward getting on or off the cart. Lift 
gently and transport carefully after having placed a towel 
over the patient's eyes and cotton in her ears if the 
surroundings are noisy. 

6. Nurses must report any leakage of hypodermic 
syringes and must use fresh tablets and never a stock 
solution. 

7. To give the hypodermic injections use this method: 
Sterilize water in a spoon and draw into the syringe three- 
fourths of the amount necessary to fill it. Place the 
hypodermic tablet in the sterile spoon and inject over it 

33 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

the contents of the syringe. Dissolve thoroughly and use 
great care to suck up all of the solution. Free the syringe 
from air, but do not lose a drop of the solution by so 
doing. Inject deeply and inject every drop. If these 
precautions are not taken, it is easy to start with J4 grain 
of morphine and give the patient y% grain, and the surgeon 
will consider the drug variable and unreliable. 

8. The nurse need not be in constant attendance on 
the patient until the latter is conscious, but the patient must 
be seen at least every fifteen minutes during the first four 
hours and every half-hour for the next four hours after 
the operation unless there is another patient or a relative 
in the room with her. 

9. When the patient is returned to her bed from the 
operating room, have at least one pillow to elevate the 
head; or, if the nature of the operation will allow, place 
her in a sitting position with the bed rest. Do not remove 
the pillows or place a towel over the head of the bed or 
over the pillows, and if you must have a pus basin near in 
case of vomiting, put it out of sight of the patient, for it 
will be hours before she vomits, if at all. 

10. The same nurse should administer all the injections 
to each patient and only two doses (the first and the sec- 
ond) should be given in the patient's room. The third 
dose should always be given in the operating room and 

34 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

should be ordered by the anaesthetist after she has seen 
the patient. 

11. Catheterize the patient after she is in the operating 
room. The secretion of urine is often so rapid that the 
bladder will contain at the time of operation from two to 
eight ounces of urine, if the patient is catheterized in her 
room just before being carried to the operating room. 

There are many minor details which the anaesthetist may 
learn by close observation. Paralysis of the jaw or tongue 
does not occur in one per cent of cases — so rarely that the 
necessity for removing false teeth is not often found. In 
fact, I strongly advise leaving in the upper set. In case 
both upper and lower are false, remove the under and 
leave the upper. Patients practically never vomit on the 
table, even though chloroform and ether are given to 
deepen the anaesthesia. I have known of only one patient 
who defaecated on the table, and that was due to an 
unfinished preparation. 

The length of the anaesthesia extending over four to ten 
hours makes it important to place the arms and legs in a 
perfectly comfortable and well supported position. I have 
had a number of patients who had a temporary paralysis 
of one or both arms after the anaesthetic, one at Provident 
Hospital, one at Passavant Hospital, one in Hackley Hos- 
pital (Muskegon, Michigan), one in St. Joseph Hospital 

35 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

(Joliet, Illinois), and two at Mary Thompson Hospital. 
In each case there was no adjuvant used to complete the 
anaesthesia and the effect of the anaesthesia was especially 
prolonged. 

The mouth and air passages are always dry and the 
patient can be made more comfortable by having at hand 
a swab of cotton moistened with sterile water to wet the 
mouth and lips. No mucus will ever be found rattling 
in the throat or trachea. The reflexes are weakened or 
abolished, so that the degree of anaesthesia cannot be 
judged by them. 

The pupil will be dilated or contracted, depending on 
the greater susceptibility of the patient to the scopolamine 
or to the morphine. 

The guide to giving more or less of ether or chloroform 
is the amount of resistance shown by the patient. 

If the patient offers resistance during the operation, and 
the manipulation is to be continued, more of the adjuvant 
is indicated; and it is right here that the success of the 
anaesthetic leaves the realm of the mathematical problem 
and becomes an art. 

The operator and the anaesthetist should understand the 
areas of great sensitiveness and those that have little or 
no sensation. 

The steps of the operation should be known to the 

36 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

anaesthetist as well as to the operator, so that when sensi- 
tive areas cannot be rendered insensible by local anaesthesia 
the scopolamine-morphine anaesthesia can be deepened with 
chloroform or ether. In order to prevent an anaesthetist 
who is not accustomed to this anaesthetic from giving too 
much chloroform I instruct them to give it in this manner: 

"Drop slowly five drops of chloroform on the mask; 
stop dropping, count five slowly; drop five drops again on 
the mask; stop dropping and count five slowly; continue 
until I say, 'Stop!' Do not remove the mask." When I 
see that I am going to need a little deeper anaesthesia 
again, I say: "Now drop {\ve drops, count five"; and this 
is continued until I say again, "Stop!" In this way I have 
had most satisfactory results with a very untrained person 
dropping the chloroform. And although it puts a greater 
responsibility on the operator, it does not compare with 
the annoyance and anxiety of having a patient who is 
asleep with morphine-scopolamine given as much chloro- 
form or ether and given by the same method that would 
have been followed had no morphine-scopolamine been 
administered. 

For a painful dressing, dilatation of rectum, cystoscopy 
or some slight surgical procedure, one dose of 1/50 grain 
scopolamine and % grain morphine will be found to be 
quite sufficient and most satisfactory. The patient will be 

37 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

under its influence in three-quarters of an hour and will 
remain under the anaesthetic for at least three hours after 
the administration of the dose. 

Chloroform and even ether act so quickly when the 
patient is under morphine-scopolamine that it is never 
necessary to begin its administration more than one or two 
minutes before needed. I usually do not begin chloroform 
anaesthesia until after I have the knife in my hand, and 
occasionally not until after the skin incision has been made. 

Some patients need only two doses of scopolamine-mor- 
phine and others may have the third dose of the scopola- 
mine or of the morphine reduced or omitted. 

When the respirations are below 8 the third dose is 
omitted if the patient is well asleep, if not, give 1/100 gr. 
of scopolamine and no morphine; if the patient is very 
excitable after the second dose give 1/8 gr. of morphine at 
the third dose and no scopolamine. After 60 years of age 
the dosage should be cut down to one-half or one-fourth 
and the same rule applies to cases in which we have heart, 
lung or kidney disease. 



38 




CHAPTER IV 

Administration for Obstetrical Anaesthesia 

HE administration of morphine-scopolamine for 
surgical anaesthesia and the administration of 
scopolamine-morphine for obstetrical anaesthesia 
offers a marked difference. For surgical anaes- 
thesia we give as large a dose of morphine as possible and 
only enough scopolamine to overcome its disagreeable 
effects, increase its power to relieve pain and induce sleep. 
But for obstetrical anaesthesia we give as much scopolamine 
as possible and only enough morphine to overcome the 
excitement that would result from giving scopolamine 
alone. 

In surgical anaesthesia we desire a greater or less degree 
of relaxation and absolute quiet, and to secure this the 
patient must be unconscious and too deeply asleep to be 
aroused by manipulations or sensations of pain. In an 
obstetrical anaesthesia we desire unconscious sleep between 
pains and such a degree of anaesthesia during pains that the 
patient will not make muscular efforts during the first stage 
or inhibit efforts during the second stage. The anaesthesiae 
are so different, as well as the dosage, that I would like 
to give to the surgical anaesthesia the name morphine- 
scopolamine anaesthesia and to the obstetrical anaesthesia 
the name scopolamine-morphine anaesthesia. The obstet- 

39 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

rical anaesthesia is produced and maintained in the follow- 
ing way: 

As soon as the patient is known to be in labor she is 
given the initial dose — 1/100 grain of scopolamine and }i 
grain of morphine — after which she is prepared locally, 
examined and given a colonic flush. This will consume from 
twenty to thirty minutes, and by this time the patient will be 
drowsy and glad to go to bed. She is then conducted to 
the delivery room and put to bed in a sectional delivery 
bed (Plate I). If the pains are strong and frequent, 
1/100 grain of scopolamine is repeated every half-hour for 
two or three doses, but if the pains are feeble and infre- 
quent, 1/100 grain of scopolamine is repeated every hour 
for two or three doses. The initial dose and two following 
at one-half or one hour intervals usually suffices to put the 
patient under the anaesthetic. 

The degree of anaesthesia may be tested in the following 
way: between pains one should not be able to arouse the 
patient by addressing her; in many cases, no matter how 
loudly you speak her name, she does not respond; during 
pains she should not be able to make co-ordinate move- 
ments, even though capable of making violent inco-ordinate 
movements. These tests we have named the Calling test 
and the Inco-ordination test. 

The condition called the Calling test — or the inability 

40 




Plate III. Bed With Screen Adjusted. 




Plate IV. Bed With Canvas Partially Adjusted. 



SCOPOLAMIXE-MORPHIXE ANAESTHESIA 

to answer to a call — is many times obtained earlier than 
the Inco-ordination test. If both are present, your patient 
is under the anaesthetic and will not need another dose for 
two hours. If only one test is present and that the calling 
test, and the labor is advancing rapidly as indicated by 
frequent and severe pains, you will be wise if you give 
the fourth dose at the one-half hour or hour interval. 

After the anaesthesia has been produced (and that will 
be after the third or fourth injection), the vulva may be 
prepared by the use of an antiseptic solution, a large 
sterile pad applied and the obstetric envelope (see Plates 
X, XI, XII) put on the patient. Also a gown, the chief 
features of which are a continuous sleeve (see Plates XIII, 
XIV) and a Rubin shirt fastener. Incidentally, this con- 
tinuous sleeve provides a convenient test for inco-ordination 
by simply throwing it over the patient's head; if co-ordina- 
tion is lost, the patient will not be able to raise her head 
and slip the sleeve over it. 

At this time specially constructed screens (Plate III) 
are placed completely surrounding the delivery bed. A 
canvas cover (Plate IV) with overhanging sides has been 
placed under the mattress and the sides are now lifted 
and securely tied to the tops of the screens. By so doing, 
the bed is converted into a canvas crib (Plate V) with 
sides two and one-half feet high. 

41 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

As the pains increase in frequency and strength, the 
patient tosses or throws herself about, but without injury 
to herself, and may be left without fear that she will roll 
onto the floor or be found wandering aimlessly in the 
corridors. In rare cases, where the patient is very excitable 
and insists on getting out of bed, 1/32 grain of morphine 
may be given and repeated in one-half hour if necessary; 
but I prefer to fasten a canvas cover over the tops of the 
screens, thereby shutting out light, noise and possibility of 
leaving the bed. From now on until the head is ready to 
deliver the patient needs not be touched except to be given 
every two hours 1/100 grain of scopolamine to maintain 
the anaesthesia. 



42 



11 



CHAPTER V 

Typical and Atypical Cases 

YPICAL cases of morphine-scopolamine — i. e., 
surgical anaesthesia — feel drowsy about twenty 
minutes after the first dose and always fall 
asleep before the end of an hour. The sleep 
deepens after the second injection and the patient will not 
rouse or notice the third injection. The face begins to 
flush after the second dose and the mouth and throat 
become dry. The pupils are slightly dilated and the patel- 
lar reflexes diminished. After the third dose the face is 
deeply injected, almost swollen, in appearance, the mouth 
and throat dry and the patient at intervals sucks the 
tongue. Pupils are dilated, the patellar and pupillary 
reflexes absent and Babinski marked in the right foot. 
Up to this time the patient makes no attempt to speak, 
but will answer questions very intelligently until half an 
hour after the second dose. 

When the patient is placed on the cart to be taken to 
the operating room she will make no effort to help herself 
unless it be to lift up the head or to grasp the cart tightly 
with her hands, apparently in great fear of falling. 

After being placed on the operating table she may open 
her eyes and look about or attempt to lie on her side or 
to draw her knees up, but in two or three minutes she is 

again in a deep sleep. 

43 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

The skin is often sensitive, but after the skin and 
peritoneum are incised the appendix may be removed or 
a gastroenterostomy may be performed without starting 
a reflex. 

The patient is sensitive to light and noise until after the 
third dose, but for two hours after the third dose light 
and noise do not disturb the patient. This is the period of 
deepest sleep. Two hours after the third dose the sleep 
begins to be lighter and four hours after the third dose 
the patient is nearly conscious. The flush begins to leave 
the face two hours after the third dose, but the mouth 
remains dry for eighteen hours after the third dose. The 
pulse has been slightly accelerated and force increased after 
the second dose, but after the third dose the pulse gradu- 
ally drops until as the anaesthetic wears off it is a few beats 
lower than before the anaesthetic was begun. The respira- 
tions remain practically unchanged. Four hours after the 
third dose the patient will be able to converse intelligently, 
but will have no memory of it on the following day. 

During the operation the patient will make an occasional 
remark — saying that she is suffering pain or making some 
incoherent reference to her personal affairs. 

Sight is often disturbed for one or two days. The 
patient sleeps the greater part of the time for sixteen 
hours after the third dose. When the patient wakens it is 

44 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

as from a refreshing sleep, with no sensation of pain, 
nausea or disturbing dreams, and remembers nothing after 
the second dose was given. If too much water is drunk, it 
may be suddenly rejected ten or twelve hours after the 
operation; but the vomiting will not be attended with 
nausea. The patient will sleep poorly the first night fol- 
lowing the operation, but will have little or no pain. 

In a typical case of scopolamine-morphine — that is, 
obstetrical anaesthesia — the patient will fall asleep in 
twenty or thirty minutes after the initial dose, and the 
sleep will gradually deepen, so that between pains the 
patient cannot be wakened, but will roll over or toss about 
in the bed during the pains. As the pains increase in 
strength, however, the patient seems more restless and 
more awake. As the first stage nears the end, the patient 
usually sits in a squatting position in the bed and between 
pains sleeps with the head resting against the canvas sides 
of the crib. 

At the beginning of the second stage inco-ordinate 
efforts are made by the patient to go to the bathroom, and 
constant references are made regarding that necessity — 
none of which need be heeded unless examination of the 
abdomen indicates a full bladder, in which case she may 
be catheterized. 

As soon as the expulsive stage arrives, the patient lies 

45 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

down again and from this time on the perineum should be 
watched at intervals for bulging. 

When the head is seen at the vulvar orifice the canvas 
sides are let down, the sectional bed disjointed and the 
upper section shoved to a convenient position in the room 
(Plate VII). The Bierhalter stirrups are put in place, 
the obstetric envelope removed, the continuous sleeve 
slipped over the patient's head, the legs secured in the 
stirrups and a broad band of webbing applied to the thighs 
in the form of a double spica and the ends fastened to the 
iron rod at the end of the bed (Plate VIII). The placing 
of sterile sheets completes the preparation for delivery 
(Plate IX). 

No haste need be made and no ether or chloroform 
given, for the delivery of the head will be quite as slow as 
the most careful obstetrician could desire. If the patient 
is put into the stirrups too early the smoothness of the 
delivery is greatly interfered with; and it is equally impor- 
tant to convert the bed into a crib as soon as the patient is 
under the scopolamine-morphine anaesthesia. 

The head requires no holding back, and need not be 
delivered between pains to preserve the perineum. The 
patient is never instructed to bear down or not to bear 
down and — except while the head is being delivered — 
should not be coerced in any way. 

46 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

The restraint given by the canvas sides of the bed and 
the continuous sleeve, though slight, will be resented by 
the patient. 

If you desire to waken the patient between pains, 
strongly flex the head on the chest for a few seconds and 
by relieving the anaemia of the brain you will have a fairly 
ready response (Plate XV). 

In the obstetrical anaesthesia where we give a larger 
amount proportionately of the scopolamine we often 
notice an increasing sensitiveness with every dose injected. 
The patient may not notice the first prick of the hypo- 
dermic needle, but each succeeding prick seems to be more 
annoying to the patient; but after the delivery, when the 
patient wakes up, she has no memory of any injection 
after the first one or two. 

Even in surgical anaesthesia, when after the third dose 
sensitiveness to light and sound has disappeared, the 
sensitiveness to touch will still be strong. The one memory 
common to the majority of patients is of being taken in an 
elevator. Only a few have any memory of the operating 
room, and describe it as seeing "lights." 

Atypical cases may be produced by giving morphine- 
scopolamine in a hospital where it is not usually given and 
where nurses and internes are not acquainted with the 
anaesthesia. I performed an appendectomy on a young 

47 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

man 25 years old in a small two-story hospital with no 
elevator and the operating room in the basement. I 
ordered the patient to be brought to the operating room 
fifteen minutes after the third dose. When the time came 
for his arrival I was greatly annoyed and surprised to see 
the patient walk into the operating room and climb onto 
the table with very little assistance. He had walked the 
length of a long hall and down two flights of stairs to the 
operating room. After lying on the operating table ten 
minutes he was so soundly asleep that the appendix, which 
was ruptured, was removed without the patient taking any 
other anaesthetic except the three doses of morphine- 
scopolamine. 

A similar, though annoying, experience occurred in one 
of our best managed hospitals, where I had operated many 
times under morphine-scopolamine anaesthesia. In this 
case, after the patient had received her third dose, she was 
awakened and with some difficulty assisted into a wheel 
chair and taken to the anaesthetic room adjoining the 
operating room. Here she fainted away while being 
assisted out of the wheel chair. I ordered her taken back 
to her room and postponed the operation until the follow- 
ing day. 

One patient, who had had an extensive resection of the 
saphenous veins on both legs for the relief of varicosities, 

48 




Plate V. Bed With Canvas Adjusted Forming a Crib. 




Plate VI. Patient in Crib Bed Ready for Examination. 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

slept quietly during the afternoon and evening following 
the operation, but about midnight was found wandering in 
the corridor. When asked what she was doing she replied 
that she was going to call her husband to breakfast. She 
was put back in bed, but had no remembrance of her 
escapade the next morning. 

The fact that there is no cumulative effect in scopola- 
mine-morphine is well illustrated by a patient who entered 
the hospital for inguinal hernia. He was given 1/100 
scopolamine and y± morphine at 5:00, 6:00 and 7:00 
a. m., and was ready for operation at 7:30 a. m. I hap- 
pened to be in attendance on an obstetrical case that was 
making such progress that I was quite sure it would ter- 
minate by 7 :00 a. m. — in time for me to operate at 8 :00 
or 8:30 o'clock. The case, however, hung on until 2:00 
p. m., when I telephoned the hospital that if the patient 
was not asleep to repeat the same dose given in the morn- 
ing and that I would operate at 4:30. The nurse misun- 
derstood the message, and although the patient was not yet 
conscious, the scopolamine-morphine w r as repeated so that 
the patient had \]/ 2 grains of morphine and 6/100 grains 
of scopolamine in six doses over an interval of ten hours. 
The operation was performed at 4:30 p. m. and the 
patient awoke the next morning at 8 :00 with no remem- 
brance of anything that had happened on the previous 

49 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

day. Convalescence was normal, save an erythema over 
the greater part of the body, which appeared on the 
eighth day and disappeared on the tenth. 

The mental condition of the patient is a very poor 
guide to the amount of amnesia or analgesia present. 

In one of my early cases the patient, a foreign-born 
woman, was brought to the operating room apparently 
wide awake. Instructions were given not to begin the 
ether anaesthetic until ordered. The field of operation 
was prepared and curettage performed, without any com- 
plaint from the patient. The patient looked around the 
room, and at the conclusion of the curettage asked for 
a glass of water and drank it. The operation was con- 
tinued with a trachelorrhaphy and anterior colporrhaphy, 
at the conclusion of which the patient drank another glass 
of water. The final step in the operation was a perineorrha- 
phy, after which the patient drank a third glass of 
water. She was taken to her room after the operation, 
and those who had observed the anaesthetic attributed her 
being awake, speaking and drinking and yet making no 
movement of the body, to the fact that she was foreign 
born and could bear pain better than our American 
women. She spoke with her husband in her room after 
the operation and after he left she went to sleep. She 
awakened in the evening, when her husband returned, and 

50 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

asked when her operation was going to be done. It was 
with great difficulty that she was convinced that the oper- 
ation had been done ten hours previously. 

When scopolamine is given without morphine, or in 
great disproportion, one is likely to have a very trying 
experience. Twice it occurred that through a misunder- 
standing of the attending physician the patient was given 
three doses of scopolamine, each 1/150 grain, with no 
morphine. The patient slept quietly when not moved or 
touched, but the slightest touch roused her and she became 
a perfectly uncontrollable maniac. It was not possible to 
take her on a cart to the operating room without first 
giving her chloroform. The patient required very little 
chloroform and save for the annoyance the anaesthesia was 
satisfactory. 

To those who are unaccustomed to morphine-scopola- 
mine anaesthesia the occasional lowering of the respirations 
causes much anxiety. One of the remarkable facts is that 
these patients are not the patients who are most likely to 
be cyanotic. I have watched for an hour a patient whose 
respirations were two in three minutes. At no time were 
the respirations shallow or was there any cyanosis or 
weakening of the pulse. 

Another source of anxiety is the occasional increase of 
pulse rate after the second dose — I have noted an increase 

51 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

of fifty beats — but the force and fullness of the pulse 
allayed any anxiety, and after the third dose the pulse 
dropped to normal or a moderately increased pulse rate. 

Cyanosis appears more frequently in thin, poorly nour- 
ished patients than in any other. In the early experience 
with this anaesthesia we saw more than we see now, and it 
is probably due to the fact that now we never give a third 
dose except in the operating room, and a patient who 
would become cyanosed gets a smaller dose of morphine in 
the third dose, i. e., 1/100 grain of scopolamine and }i 
grain instead of *4 grain of morphine, and the cyanosis is 
prevented. 

Tubercular patients have occasionally given trouble, so 
much so that we advise especial attention to be paid to the 
dosage of such patients. 

One patient, age 28, tubercular, constantly coughing, had 
the uterus emptied of a three and one-half months' preg- 
nancy; operation lasted 40 minutes. She had only two 
doses of scopolamine 1/100 grain and morphine 1/6 grain. 
She lost considerable blood during the operation, respira- 
tions were shallow and pulse weak. Stimulants were given 
and she left the operating room in good condition, as regards 
pulse and respiration. The patient was wheeled into an 
adjoining room to be taken later to her own room. In ten 
minutes after leaving the operating room the patient was 

52 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

pulseless and no respiration; by stretching the anal muscle, 
gasping respirations were established; when efforts ceased, 
the patient ceased breathing. Artificial respiration was not 
very successful, but was resorted to. Both legs were 
bandaged from toe to the body and a tank of oyxgen was 
administered, also heart stimulants; color of the patient 
returned and the respirations became more regular, and 
fifteen minutes after the pulseless condition the patient 
spoke regarding her children. She made an uneventful 
recovery, leaving the hospital in as good condition as when 
she came. 

Another patient, 40 years old, a Hebrew, markedly tuber- 
cular, was deeply cyanosed and respirations ceased on her 
return to her bed after the operation. Administration of 
oxygen put the patient in good condition in two minutes 
and she became conscious immediately. 



53 



CHAPTER VI 

Report of 5,000 Morphine-Scopolamine 

Anaesthesiae 

operation for no. 

Cholecystotomy 38 

Cholecystectomy 23 

Exploratory Coeliotomy 35 

Amputation of Cervix 461 

Trachelorrhaphy 57 

Colporrhaphy 283 

Perineorrhaphy 650 

Modified Longyear 3 

Pelvic Abscess 41 

Removal Cervical Polyp 88 

Excision of Vaginal Cyst 9 

Curettage — 

Endometritis 332 

Menorrhagia 148 

Dysmenorrhea 512 

Incomplete Abortion 278 

Carcinoma of Cervix 93 

Diagnosis 267 

Incision of Abscess 158 

Excision of Lipoma 21 

Excision of Fistula 51 

Ingrowing Toenail 67 

55 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Infected Hand 14 

Removal of Foreign Bodies — 

Bladder 5 

Uterus 2 

Buttock 1 

Hand 6 

Foot 8 

Papilloma of Bladder 3 

Urethral Caruncle 40 

Valvovaginal Abscess 48 

Valvovaginal Cyst 26 

Laceration of Urethra 3 

Freeing of Clitoris 46 

Hemorrhoidectomy 98 

Dilatation of Sphincter Ani 27 

Ischio-rectal Abscess 13 

Rectovaginal Fistula 7 

Breast Operations — 

Radical 31 

Amputation 3 

Removal Tumor 16 

Excision of Cervical Glands 8 

Hallux Valgus 19 

Removal Coccyx 32 

Trephining 4 

56 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Thyroidectomy — 

Exophthalmic 10 

Hypertrophy 22 

Watkins Wertheim 78 

Varicose Veins 15 

Jejunostomy 1 

Gastrectomy 4 

Drainage Pancreatic Cyst 1 

Drainage Common Duct 12 

Cystoscopy 127 

LeFort 6 

Removal of Hymen 28 

Gastrotomy 3 

Gastroenterostomy 12 

Resection of Small Intestine 12 

Resection of Large Intestine 6 

Hysterectomy — 

Abdominal 220 

Vaginal 265 

Oophorectomy 298 

Ovariotomy 187 

Resection of Ovary 157 

Salpingectomy 516 

Oophorectomy and Salpingectomy 191 

Broad Ligament Cyst : 10 

57 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Ventral Fixation of Uterus 146 

Round Ligament Shortening 438 

Hernia — 

Umbilical 26 

Inguinal 46 

Femoral 18 

Ventral 28 

Linea Semilunaris 1 

Appendectomy 770 

Myomectomy 217 

Nephrectomy 8 

Total, 7,954 operations on 5,000 patients. 

This list of operations gives an idea of the character of 
the operations so that anyone can readily understand the 
general applicability of this anaesthetic to almost every 
field of surgery. 

In the list are no tonsillectomies, no Cesarean sections, 
no operations on children, for the reason that we have 
always considered age under twelve years, throat opera- 
tions and obstetric operations a contra-indication to mor- 
phine-scopolamine anaesthesia. Throat operations require 
an anaesthetic of short duration, and one from which the 
patient may recover quickly enough to keep the blood out 
of her trachea and oesophagus. The other contra-indications 

58 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

are based solely on the fact that children cannot be 
given morphine except in very small doses, too small to 
give us any general anaesthesia effect. 

The deaths occurring in this group of patients numbered 
twenty-seven — that is, less than three-fifths of one per cent 
mortality. Some of these deaths do not properly belong 
to this record. For example, No. 4308 died two months 
after the operation, of chronic nephritis — which was ad- 
vanced when she entered the hospital for an emergency 
appendectomy. No. 4252, dying three weeks after oper- 
ation, had advanced pulmonary tuberculosis when the 
abdomen was opened for tubercular peritonitis. No. 2768 
was an exophthalmic goitre, whose death we had expected 
many times during the three months preceding the opera- 
tion. No. 4820 was brought to the hospital with general 
septic peritonitis, streptococcus infection; drainage insti- 
tuted. No. 932 had an ulcer of the stomach that had 
perforated more than twenty-four hours before I saw her. 

In such cases not only the anaesthetic, but the operation, 
is not responsible. It is notable that we lost no patient as 
the result of curettage; and this includes many patients 
who were in a bad general condition at the time the 
anaesthetic was administered. One had five per cent sugar 
in the urine; many were depleted by hemorrhages, and 
others were septic. No patient having a breast operation 

59 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

died, although one was 84 years old, and the breast, 
besides the carcinoma, contained many ounces of pus. She 
was brought to the hospital on a stretcher, moribund, not 
expecting an operation, and in two weeks was walking. 

No gastroenterostomy or gastrectomy died, and one was 
a feeble man IS years old with carcinoma of the stomach. 
He is still alive, seven months after the operation. 

No patient died after trephining. A broad ligament 
tumor operation is one of the most difficult operations if 
the tumor is large. We had ten, all large, and one 
weighed fifteen pounds; yet no mortality. Perhaps one of 
the best tests for the anaesthetic was 438 round ligament 
operations without a death. 

Taking up the mortalities in detail — 

We have No. 2768 and No. 4812 exophthalmic goitre. 
No. 2768 was kept on medical treatment for a number of 
months before entering the hospital, but with no improve- 
ment. She was in no condition to have an operation, but 
was herself very anxious for an operation. She was kept 
in bed in the hospital for four weeks and finally, at the 
earnest solicitation of the patient and relatives, the opera- 
tion was undertaken. The pulse was 130 and respirations 
were 32 before operation, while during the operation and 
under the morphine-scopolamine anaesthesia the pulse was 
120 and respiration 28. When I left the hospital four 

60 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

hours after the operation she was in as good condition as 
she had been at any time before, but shortly after I left 
the heart became irregular and weak and she died about six 
hours after the operation, without regaining consciousness. 

No. 4812 was a young girl with a large goitre sur- 
rounding and making pressure on the trachea. The right 
lobe was removed without any difficulty, but when the 
middle lobe was lifted, or any traction made, the patient 
had a spasmodic breathing with accompanying cyanosis. 
The operation was stopped three times to allow the patient 
to breathe normally again, but the fourth time the patient 
stopped breathing and it was impossible to resuscitate her; 
she died on the operating table. 

Four cases died who had operations for gall bladder 
disease. No. 782, 51 years of age, had carcinoma of the 
gall bladder and ducts; the stones were removed, but it 
was impossible to secure any bile from the occluded ducts. 
The patient was intensely jaundiced and she died of ex- 
haustion on the ninth day after the operation. 

No. 820 was a nun 54 years of age, with stones and 
infection of the gall bladder of long duration. She was 
very feeble and with lowered resistance. I believe more 
extensive drainage should have been used. She died on 
the fourth day from toxaemia, with acute dilatation of the 
stomach. 

61 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

No. 769 had been in bed for several weeks, was much 
wasted and very feeble. When the abdomen was opened 
carcinoma of the stomach was found with occlusion of the 
bile ducts. The gall bladder was drained, but the patient 
stood the operation poorly and died on the third day, 
never having completely recovered from the shock of the 
operation. 

No. 4981 was operated upon for gall bladder disease. 
She was deeply jaundiced and had been so for weeks. The 
gall bladder was removed and the common duct explored 
and drained. The patient died of toxaemia on the fourth 
day. 

Three deaths were the result of hysterectomy. 

No. 438 was vaginal hysterectomy for acute infection 
following a criminal abortion. The patient came to the 
hospital with peritonitis and pus tubes. An effort was 
made to drain through the posterior cul de sac. The 
patient not improving, the uterus was removed in the hope 
of establishing free drainage and removing pus foci. The 
patient died of septicaemia on the seventh day. 

No. 3980 was an operation for complete prolapse. The 
patient stood the operation well, but died quickly as the 
result of a secondary hemorrhage on the third day. 

No. 4060, aged 45, was a supra vaginal operation for 
large fibroids; the patient was depleted by frequent hemor- 

62 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

rhages before entering the hospital; stood the operation 
well. I saw her in the morning and considered her in good 
condition; one hour after leaving the hospital I was tele- 
phoned that she had no pulse and was dying. No post- 
mortem was held and the death certificate stated thrombus 
as cause of death. 

No. 2060 was an advanced carcinoma of the uterus; the 
patient had been having hemorrhages and had lost a great 
deal of blood during the operation, owing to an involve- 
ment of the bladder. She died of shock and loss of blood 
twelve hours following the operation. 

No. 2998 had a hysterectomy and cholecystectomy. The 
patient died on the eighth day with streptococcus infection; 
infection not known to be present before the operation. 

No. 3675 and No. 4791 were uncomplicated perineor- 
rhaphies. Both died of streptococcus infection and were 
not known to be infected before the operation. No. 3675 
died on the twelfth day; No. 4791 on the thirty-ninth day. 

No. 932, 65 years old, had an exploratory operation in 
the night at her private home in the country. I found 
the abdominal cavity filled with stomach contents from 
perforated ulcer of the stomach. The patient died of 
peritonitis on the second day. 

No. 3645. The patient had a very large ruptured 
ovarian cyst and myxomatous peritonitis. Extensive adhe- 

63 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

sions were found everywhere and kept up constant oozing. 
The patient died at the end of twenty-four hours from 
exhaustion and shock. 

No. 3110 and No. 3313 had had a salpingectomy for 
pus tubes. Both died on the fourth day with septic 
peritonitis. 

No. 3910 died on the twenty-first day following a 
jejunostomy. The patient had a malignant papilloma of 
the stomach, inoperable, and the jejunostomy was merely 
palliative. 

No. 4252 had an extensive and advanced tubercular 
peritonitis. Tubercular tubes and ovaries were removed, 
but the patient had pulmonary tuberculosis and died on the 
twenty-first day, exhausted by the general tubercular 
infection. 

No. 2987 had an operation for a large ventral hernia. 
She had asthma, with a history of attacks resembling 
angina. She was profoundly affected by the anaesthetic, in 
contrast to a patient who had a similar operation the hour 
before and who was scarcely asleep, although the same 
dose was prescribed. Some time after the patient's death 
— which occurred twelve hours following the operation — 
it was discovered that the patient who died had had four 
doses of scopolamine and that the patient operated on the 
hour before had had only two doses. This mistake arose 

64 





Plate VII. Bed Disjointed and Preparation for Delivery Begun. 




Plate VIII. Preparations for Delivery Complete Except Sterile Covers. 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

on account of the patients lying in adjoining beds and 
having foreign names almost identical. A change of 
nurses had been made after the first doses had been given 
and before the last doses were due, and the first patient 
had received four doses in two hours' time and the second 
patient two doses with an interval of one and one-half 
hours between. 

No. 4611 and No. 4308 died of general peritonitis due 
to ruptured appendix. 

No. 4820 had an exploratory incision with drainage 
introduced for general peritonitis with streptococcus in- 
fection. 

No. 3612, 45 years old, alcohol and opium habitue, was 
convalescent from operation for chronic appendicitis and 
retroversion. She was to have gone home on the follow- 
ing day. As the nurse was bringing in the tray for her 
supper, the patient gasped, "Oh, my heart!" and when 
the internes reached her room there was no sign of life. 
No post-mortem was held, and the death certificate gave 
thrombus as the cause. 

No. 2114, 49 years old, had a strangulated umbilical 
hernia and died suddenly on the fifth day from a thrombus. 

No. 3841 had a papilloma of the bladder. The growth 
was removed through a supra-pubic incision; hemorrhage 
was profuse at the time of the operation and continued 

65 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

after the operation. The patient died in twenty-four hours 
as a result of loss of blood. 

No. 4980 had septicemia due to infection from the pelvis 
of the kidney. She was in very poor general condition 
at the time of operation — which consisted in putting drain- 
age in the kidney and making an exploratory abdominal 
operation. The patient died of sepsis on the fifth day. 

These deaths date back to 1904, and it can very easily 
be seen that no death could be attributed to the morphine- 
scopolamine anaesthesia. The death rate from all causes 
is between one-half and three-fifths of one per cent, and 
surely with routine cases unselected one could hardly 
expect a lower mortality with any anaesthetic. The mor- 
tality, I believe, is low because of the use of scopolamine- 
morphine anaesthesia — especially in those cases where the 
patient is in poor general condition with nephritis or dia- 
betis or where the patients are suffering from irritability 
of the nervous system, as in asthma or from hyperthryoid- 
ism in goitre. 

It is of interest that six per cent of these patients showed 
albumen granular casts or sugar in the examination of 
urine made before operations, while only one per cent 
showed albumen granular casts or sugar after operations. 
Patients with asthma breathe quietly under the anaesthetic 
and may even be placed in the Trendelenburg position dur- 
ing operation. 

66 



SCOPOLAMINE-MORPHINE ANAESTHESIA 



Effect of Morphine-Scopolamine Anaesthesia on 
the Respiration 



Table I 



Change in Respiration 


Doses 3 each 

1/ 150 gr. scopolamine 

1/6 gr. morphine 


Doses 3 each 

1 /100 gr. scopolamine 

1/4 gr. morphine 


Below 14 


26% 


23% 






Between 14 and 10 


15% 


17% 






10 and below 10 


11% 


6% 




8 and 9 


4% 


2% 




7 


1% 


1% 




5 and 6 


1% 


1/5% 




4 


1% 


2/5% 





To compute this table the respirations were taken from 
the charts before any scopolamine injections were given 
and again after the patient returned from the operating 
room. 

It is interesting to note that the change in respiration 
is much the same whether we use the large or the small 
dose, the reason being that the proportion between the 
doses is the same — that is, 1/100 : ]/ A :: 1/150 : 1/6. 

If it is important that the respiration should not be 
changed or lowered, this may be easily effected by giving 



67 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

a much larger dose of scopolamine, as 1/50 grain scopola- 
mine with J4 grain morphine or decreasing the amount of 
morphine, as 1/100 grain of scopolamine with }i grain of 
morphine. Seventy-five per cent of the patients suffer 
little or no change in the respirations. 

If the patient is excitable or accustomed to taking alco- 
holics or opiates the respirations may be slightly acceler- 
ated. 

I observed one patient where the respirations dropped to 
two in three minutes. The patient's color was good and 
the pulse strong and apparently unaffected. Nothing was 
done for or given to the patient to quicken the respiration, 
and she made an uneventful recovery. 

The lowering of the respirations takes place about an 
hour after the second dose and respirations may continue 
low in these cases for hours after the operation. Any 
irritation of the respiratory passages is unusual. I know 
of no case having pneumonia and only two having a 
bronchial inflammation. 

Eleven patients subject to asthma have been given the 
anaesthetic and when under it had no difficulty in breathing. 



68 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Effect on the Circulation 
Table II 



Pulse 


After Second Dose 


After Operation 


Morph. 1/4 gr.'Morph. 1/6 gr. 
Scop. 1 / 100 gr. Scop. l/150gr. 


Morph. 1/4 gr. 
Scop. 1/100 gr. 


Morph. 1 /6 gr. 
Scop. l/150gr. 


From normal to above 
100 






7% 


19% 










Raised 40-50. . 


3 % 














Raised 30-40 


5 % 


4% 












Raised 20-30 


10 % 


7% 












Raised 10-20 


163^% 


34% 


24% 


13% 






Raised 2-10 


26 % 


23% 


17% 


24% 


Unchanged 


12^% 


4% 


11% 


16% 


Lowered 2-10 


21 % 


22% 


41% 


28% 


Lowered 10-20 


SV 2 % 


6% 













We here note after the second dose an increase in the 
frequency of the pulse, while after the operation the fre- 
quency is decreased or unchanged in over fifty per cent for 
the large doses and nearly fifty per cent for the smaller 
doses. This increase after the second dose is probably 
due to the fact that the scopolamine is eliminated too 
quickly for its influence to be felt after the operation. 

69 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

The little change in pulse rate after operation goes to 
show the anoci properties of the anaesthetic. Only seven 
per cent had pulse markedly raised after operation where 
the larger dosage was used, while nineteen per cent had 
pulse raised where the smaller dosage was used. 

Changes in the pulse or respiration due to the drugs 
take place at different periods, and those periods are deter- 
mined by the elimination of the scopolamine and the mor- 
phine. Scopolamine is eliminated so quickly that the effect 
of a dose is not felt two or three hours after taken, while 
the morphine is eliminated slowly; I have seen the effects 
of the morphine continue for 24 to 36 hours after the 
dose, though the usual period is 8 to 12 hours. 

In cases where the patient has been put under the 
morphine-scopolamine anaesthesia and the operation has 
been deferred for a period of two or three hours, it is 
important not to repeat the same dose of scopolamine and 
morphine to continue the anaesthesia, because by so doing 
the patient will get an overdose of morphine, the morphine 
of the previous doses not being eliminated. 

One case, No. 4990, was given 1/100 grain of scopola- 
mine and % grain of morphine at each of two doses one 
hour apart. A curettage was done under the influence of 
this anaesthetic and after the curettage it was decided to do 
a hysterectomy. The scopolamine 1/100 grain and mor- 

70 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

phine }4 grain was then repeated two and one-half hours 
after the last dose had been given. The patient slept 
profoundly from this time (10:00 a. m.) to 5:00 p. m., 
when she became cyanotic and her respirations slow and 
shallow. Oxygen and stimulants were given and the 
patient was conscious at 7 :00 p. m., having been under the 
influence of the anaesthetic eleven hours — the longest time 
of any patient in the series. 

But to demonstrate the anoci properties of this anaes- 
thetic it is not necessary to use a table of pulse rates, for 
anyone who has watched patients waken from a scopola- 
mine-morphine sleep and noted the happy expression of the 
face and the absence of pain and worry and marked the 
regularity and fullness of the pulse is convinced that the 
patient has been saved to a greater or less degree the 
shock of the operation. 

The blood pressure changes are fairly constant and 
marked. 

Seventy per cent had the blood pressure raised from 10 
to 70 points, sixteen per cent were raised above 20, while 
four per cent were raised above 30. The greatest raise 
noted in any patient was 70, the greatest reduction was 44. 

Ten per cent showed no change in blood pressure. 

Twenty per cent were lowered, but it was in those 
patients, with few exceptions, whose blood pressure was 
130 or above. 71 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Seventeen per cent of the patients had blood pressure 
above 130; all these were reduced by the anaesthetic except 
two per cent. Four per cent had blood pressure below 100 
and all of these were raised by the anaesthetic. 

Thirty- four per cent had blood pressure between 100 
and 120 and all raised except two per cent. 

These observations were made on the patients, first, 
before any anaesthetic was given; second, after the last 
dose of anaesthetic, and before the operation, and third, 
after the operation. 

It was found that the blood pressure was reduced in 
the majority of patients after the operation. Sixty-three 
per cent were lowered and twenty-seven per cent continued 
raised. Three-fourths of the cases where the blood press- 
ure continued raised were abdominal operations, and I 
conclude that in the majority of cases the lowering of the 
blood pressure is due to the elimination of the scopolamine, 
which is partly effected at the end of the operation, and 
not due to the operation itself. 

Effect on the Digestive System 

The vomiting after scopolamine-morphine anaesthesia 
is rather different from the vomiting following chloro- 
form or ether. It never begins until eight or ten hours 
after the anaesthesia is begun, and often is delayed 

72 







Plate IX. Sterile Covers and Gyn. Sheet Applied. 



____________ 




Plate X. Obstetric Envelope Opened. 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

for eighteen or twenty-four hours. In the majority of 
cases the vomiting is not accompanied by much nausea and, 
like seasickness, the patient feels entirely free from dis- 
comfort as soon as the stomach is emptied. In the major- 
ity of patients there need be very little restriction as to 
water. Where there was no chloroform or ether given, 
sixty-one per cent of the patients did not vomit at all, and 
of the thirty-nine per cent that vomited, thirty-three per 
cent were appendectomies and thirty-five per cent curet- 
tages. Appendectomies are more likely to vomit than any 
other cases. Out of 114 appendectomies uncomplicated 
by any other operative procedure, fifty-one per cent 
vomited. 

Hysterectomies with appendectomies vomit in fifty-six 
per cent of the cases. 

Curettages vomit on account of poor preparation. 

Taking all cases under all dosages and with all adjuvants 
fifty-five per cent had no vomiting, thirteen per cent very 
slight. Thirty-two per cent had more than slight. Of 
this thirty-two per cent that vomited, forty per cent were 
appendectomies, twenty per cent hysterectomies, twenty per 
cent curettages. 

Washing the stomach brings quicker relief than any 
other procedure, because where the vomiting is due to the 
anaesthetic it is chiefly the mucosa of the stomach, where 

73 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

the morphine is being eliminated, that needs to be aided. 
Enemata given early also help to eliminate the morphine 
from the bowel, which, as well as the stomach, helps in 
ridding the system of the morphine. While the scopola- 
mine is present in the system we practically never get 
vomiting; only seven patients in five thousand made any 
attempt to vomit on the table and only four actually 
vomited. 

I believe that if 1/100 grain of scopolamine without 
morphine were given to the patient at the first sign of 
nausea or vomiting the vomiting might be checked at once. 
I have not used this method in a sufficient number of cases 
to make any report upon it. 

Three per cent of the patients had the bowels move on 
the fifth day. These were perineorrhaphies, ruptured 
appendices, and vaginal hysterectomies, where a late bowel 
movement was desirable. Two out of five patients had 
bowel movement on the first and second day after the 
operation. Three out of five patients passed urine nor- 
mally within twelve hours after operation. 

Four patients had an ileus and were operated for that 
condition, no fatalities resulting. Each patient had had 
an appendectomy and one had had besides the appendec- 
tomy a large broad ligament cyst removed. Two were in 
men and two in women. The patients had been the sub- 

74 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

jects of previous attacks of peritonitis and many adhesions 
were found in the abdomen and not broken up lest the 
infection present at the time of operation should be 
spread. 

Effect on the Nervous System 

Only one patient was mentally affected after taking the 
anaesthetic. No. 881 had a large ovarian cyst. She was 
36 years of age and had been under Christian Science 
treatment for a period of ten years. The tumor weighed 
52 pounds and had displaced all of the viscera, including 
the heart, whose apex beat could be felt and seen two 
inches above the nipple. No chloroform or ether was 
used as adjuvant and the patient made a rapid recovery for 
the first week, when she began to have delusions, imagining 
that hearses were passing her window and that dead 
people were being carried about the hospital. She ate well, 
the wound was healed, but she slept little at night and was 
removed to her home at the end of two weeks. Here she 
lost her delusions of funerals and began to talk baby talk 
to every one she met. Her husband took her away from 
home and they spent a month camping by one of the 
Wisconsin lakes, and she returned mentally normal and 
has remained so for the past seven years. 

The success of the anaesthetic depends so largely on the 

75 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

patient's mental and nervous condition that we have oper- 
ated on many patients without their knowledge. 

No. 870 had a chronic appendicitis and autointoxication 
from chronic constipation. She had received all the treat- 
ment usually given to neurasthenics and was at the time 
that I first saw her very poorly nourished and vomiting 
most of her meals. When an operation was proposed she 
refused and became hysterical. Her mother desired her 
to have the operation and said that she wished it could be 
done without the girl's knowledge. To her surprise, I said 
I could do so if she really wished it. I accordingly ordered 
two hypos of sterile water at 6 :00 and 7 :00 a. m. for 
two days; on the third day I ordered the hypos to be 
scopolamine and morphine instead of water. After the 
second dose she was asleep and did not know when the 
third dose was given. The appendectomy was done and 
the patient returned to her bed and propped into a sitting 
position with many pillows. She was told in the afternoon 
that I had ordered the abdominal bandage, which I had 
applied the day before, to be kept very tight and not inter- 
fered with. She did not know until the sutures were 
removed that she had had an operation. 

This was my first experience of this kind, but I have 
used this idea with great success during the past two years 
in my goitre operations. 

76 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

No exophthalmic goitre operation done by the following 
method has resulted fatally: The patient is admitted to 
the hospital and prepared for the operation. On the fol- 
lowing day, no matter what condition she is in, no break- 
fast is given, and the patient is taken to the operating room 
on a cart, placed on the operating table and given enough 
ether to render perfectly unconscious. 

The neck is covered with sterile gauze, strips of adhesive 
plaster are fastened over the neck extending from the ears 
above to the nipples below. Over this is placed a heavy 
gauze roller bandage, making the neck almost immovable. 
The patient is placed in her bed without a pillow and a pus 
basin in sight on the edge of the bed. She is not allowed 
any water until evening and then only by the teaspoonful. 
She is kept without a pillow for three days and nights and 
all visitors are restricted. The relatives and patient believe 
the operation to be done. The patient sleeps well and the 
pulse becomes more normal daily. On the fourth, seventh 
or ninth day after the fake operation, as determined by 
the pulse rate, the patient is told it is time for her to sit 
up in a day or two, and in her hearing an order is given 
for a hypo in the morning and directions about removing 
the bandages and fixing the neck. 

Three hypos are given in the morning — at 6 :00, 7 :00 
and 8 :00 — and the patient is taken to the operating room 

77 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

after the third dose (an exception to the rule that we give 
all third doses in the operating room). The operation is 
performed, if possible, without chloroform or ether being 
given and the patient is placed on a bed rest as high as 
possible when she is returned to her bed. Convalescence is 
rapid and uneventful. We have had no patient who has 
suspected that her operation was not performed the day 
after she entered the hospital. 

One of the patients who was to have a perineorrhaphy 
and repair of the urethra decided that she would not have 
an operation and refused to lie down or go to sleep after 
the hypos. When I saw her she was ready to fight if any 
one touched her, and said, "I will not have an operation!" 
No attempt was made to force her, but later in the day 
her husband and daughter arrived and were keenly disap- 
pointed that the operation was not over. They begged 
me to do it without her knowledge. 

On the morning of the next day I went to her room and 
told her I was going to give her a treatment such as she 
had had at the office. I inserted the speculum, disinfected 
an area near and gave her a hypodermic injection of 
scopolamine and morphine. At the end of an hour I 
returned to remove the packing I had left in the vagina 
and gave her another hypodermic injection of the anaes- 
thetic. The third dose was given by the nurse and the 

78 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

patient was taken to the operating room and the operation 
performed. It was not until the sutures were removed that 
she realized she had had an operation; but she still does 
not know that she was removed from her room to have 
the operation performed. 

No. 3643 came to be relieved of a large lipoma just 
above the knee on the extensor side of the leg. The tumor 
was about the size of a soup bowl and was becoming pain- 
ful. The patient was a Christian Scientist and it was more 
in a spirit of fun than of scientific interest that I decided 
to emphasize the miraculous properties of the anaesthetic. 
She was given as the first dose what was for her a large 
one — 1/100 grain scopolamine and ]/^ grain morphine. In 
ten minutes she was asleep and did not feel the second 
hypodermic injection. She was taken to the operating 
room and the incision after the tumor was removed was 
closed with a subcutaneous catgut suture and bandages 
applied. She was returned to her room unconscious and 
placed in a sitting position in bed, recovering consciousness 
in four hours after the operation. General diet was ordered 
and the only change in her life suggesting sickness was that 
she was kept in bed four days. She went home on the fifth 
day, but was told not to touch the bandages, and two weeks 
from the day of operation the leg was unbandaged and it 
was difficult to see the delicate scar line where the incision 

79 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

had been made. The patient, in amazement, exclaimed: 
"I do not understand this. When was I operated on?" 

"This," I replied, "is a miracle of modern medicine 
before which Christian Science should prostrate itself." 

Five of the patients undergoing operations were epilep- 
tics and three were insane. The epileptics did well under 
the anaesthesia and two of the insane patients recovered 
their mental health after the operations had been performed. 

The analgesic effect of the anaesthesia extends over a 
longer period than the unconscious or amnesic state. Sixty- 
five per cent of the patients under all conditions required 
nothing for pain. Twenty per cent had one or two doses 
of morphine, fifteen per cent had one dose of codeine. The 
patients requiring an opiate were largely made up of 
perineorrhaphies. The patients having anoci with the 
morphine-scopolamine anaesthesia are much less liable to 
pain and vomiting than where the anoci is not used. 

There are many regions where the anoci produced by 
the morphine-scopolamine anaesthesia is sufficient and other 
regions where local injections of novocain J4 of one P er 
cent must be used to protect the patient from pain, 

I have found through operative experience without local 
injections of novocain that the six most sensitive areas or 
structures are as follow: 



80 




X . 



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w 




Z 

w 

u 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

1. Parietal peritoneum. 

2. Skin. 

3. Perineal region. 

4. Sphincter ani. 

5. Broad ligament when traction is applied. 

6. Internal os of cervix. 
The six least sensitive areas : 

1. Mammary region. 

2. Cervix uteri and vagina. 

3. Neck. 

4. Gall bladder and stomach. 

5. Appendix and intestine. 

6. Uterus and appendages if no traction is applied. 
The obese patients are most satisfactory patients. They 

are almost sure to be able to undergo any operation with 
morphine-scopolamine anaesthesia alone. 

I know of no very obese patient who has required 
chloroform or ether as adjuvant. This fact shows the 
folly of trying to regulate the size of the dose of morphine- 
scopolamine by the body weight. 

No. 4801 was a patient weighing more than two hun- 
dred pounds. She had three doses of morphine-scopola- 
mine, and with that alone was so well anaesthetized that 
I did a panhysterectomy with many adhesions, an appen- 
dectomy, a cholecystotomy and removal of stone from the 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

common duct. She made a rapid recovery, not being 
troubled with vomiting or gas pains. 

No. 3218 had a large goitre and asthma so severe that 
every breath was labored. She had to have a radical 
breast operation for carcinoma. Three injections, each 
J4 grain morphine and 1/100 grain scopolamine, was suffi- 
cient anaesthetic for the operation, which was nearly two 
hours in length. During this time the patient breathed 
quietly, showed no cyanosis and did not waken for six hours 
after the operation. 

No. 3991 had an umbilical hernia and very pendulous 
abdomen. With only the scopolamine-morphine anaesthesia 
she had the hernia repaired and fifteen pounds of adipose 
tissue removed from the abdomen. 

It has been suggested that it is a poor anaesthetic for 
carcinoma patients, but the records of these 5,000 patients 
show that 160 patients had malignant diseases and that of 
this number four died: one died immediately after the 
operation from loss of blood before and during the oper- 
ation; the other three were inoperable cases and the oper- 
ations were for diagnosis and alleviation. 

Some of the patients have had a very rapid convales- 
cence. No. 4995 had an operation for hemorrhoids per- 
formed at 5:00 p. m.; a plug of gauze was left in the 
rectum and instructions were given to remove it at the end 

82 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

of twenty-four hours. The patient slept until 6 :00 o'clock 
the next morning and awoke with the gauze plug in her 
hand. She was feeling so well that she arose, took a bath 
in the tub and dressed. She was up and about the hospital 
all day and left the hospital on the following day. I saw 
her two weeks after the operation and she was well and 
said she had never had any pain since the operation. 

No. 4826 and No. 4732 were women physicians who had 
hysterectomies for large multiple fibroids; both were stout 
and a large incision was required. No. 4826 had had before 
operation a large internal hemorrhage due to rupture of one 
of the superficial veins of the fibroid. The abdomen was 
filled with blood when opened. Both patients resumed their 
practice, the one on the thirteenth day and the other on 
the fourteenth day, and have continued well since. 

Amounts of adjuvant used have been calculated from 
the records and found to be as follows: 

Where ether was used the average amount per hour 
was Zy 2 ounces in clinic and 2 ounces in private operations. 

The largest amount per hour was 6 ounces in clinic and 
15 ounces in private operation. 

The smallest amount used per hour was 2/3 ounce in 
clinic and y 2 ounce in private operation. 

Where chloroform was used the average amount per 
hour was 2/3 ounce in clinic and J / 2 ounce in private 
operation. 

83 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

The largest amount used was 2 ounces in one hour in 
clinic and the same in private operation. 

The smallest amount used was 1 dram in clinic and 1/3 
ounce in private operation. 

The average duration of the anaesthetic was four and 
one-half hours after the last dose was given. The longest 
time before a patient became conscious was eleven hours, 
the shortest time one hour. Forty-seven per cent of the 
patients were unconscious more than four hours after the 
last dose was given. Twenty-three per cent were uncon- 
scious less than four hours, thirty per cent were uncon- 
scious four hours. 



84 




CHAPTER VII 

One Hundred Consecutive Cases of Twilight Sleep 

at the Mary Thompson Hospital, June 1 

to December 1, 1914 

BEGAN using scopolamine in obstetrics about 

, ) eight years ago, but gave it up after a short 

'■!Sf experience. This early experience demonstrated 

to my satisfaction that scopolamine-morphine 
shortened the first stage of labor. I gave at that time 
1/100 grain of scopolamine and ]/\ grain of morphine as the 
initial dose and expected to repeat it in four hours unless the 
cervix was completely dilated. The injection was never 
given until the pains were strong and regular, and my 
experience was that at the end of two or three hours after 
the injection the cervix was completely dilated. I feared 
at this time to repeat the dose, so the labor was completed 
by using a little chloroform for the delivery of the head. 
This large dose of morphine was occasionally given so 
close to the beginning of the second stage that I feared 
that the infants would be asphyxiated on account of it. 
In no case could I have stated positively that it had caused 
asphyxia, but on theoretical grounds alone I gave up its 
use altogether in obstetrics. Then, too, my obstetrical 
work was largely made up of Cesarean sections, forcep 
deliveries, eclampsias and abnormalities, cases where the 

85 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

life of the child is always in jeopardy, and I feared that 
scopolamine-morphine used in such cases would be unjustly 
blamed for any accident that might occur. 

In 1909 I met Professor Gauss at the Sixteenth Inter- 
national Congress of Medicine, Budapest, and he urged 
me to try scopolamine in my obstetrical cases and gave an 
enthusiastic report of his work. 

But the overwhelming prejudice in the profession 
against this anaesthetic made me hesitate to enlarge the 
field of its usefulness. When the article on "Twilight 
Sleep" appeared in the June, 1914, number of "Mc- 
Clure's," I hailed it as the means of dispelling some of 
the prejudice and immediately requested the staff of the 
Mary Thompson Hospital to allow me to give scopolamine- 
morphine a trial in the ordinary routine cases of the 
obstetric service. Having had ten years' continuous use 
of this anaesthetic in surgery, and an obstetrical experience 
extending over twenty-five years, I felt I might venture to 
formulate rules and dosage for its use in obstetrical prac- 
tice without endangering the life of mother or baby. 

The dosage and the general management as worked out 
is fully described in Chapter IV. Table I demonstrates 
our results. No cases are selected and the only contra- 
indications that have been considered are lack of time or 
the necessity for immediate operative procedure. 

86 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Table I 

Primipara 58 

Multipara 42 

Lacerations in Primipara 29 

Lacerations in Multipara 7 

Hemorrhage Severe 1 j 

Hemorrhage Free 2 / 12 

Hemorrhage Slight 9 

Forceps High 2 ) 

Forceps Medium 3 13 

Forceps Low 8 

Asphyxia 11 

Resuscitation Difficult 5 

Resuscitation Easy 6 

Twins 2 

Breech 5 

Placenta Previa 1 

Pfemature 4 

Eclampsia 2 

Posterior Positions 22 

*Abnormalities. 

From this table it is seen that the lacerations in primi- 
para were fifty per cent and in multipara sixteen per cent. 
One patient had a severe hemorrhage which was the result 
of a deep tear through a congenital transverse stricture in 

87 



\26 



m 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

the vagina. Eighty per cent of the patients lost so little 
blood that it was not possible to estimate it. The uteri 
contracted immediately after delivery and showed little 
tendency to relax. 

Fourteen per cent were abnormal cases, not including 22 
posterior positions, all of which rotated anterior except 
two. 

Three of the five breech infants and two with eclamptic 
mothers had to be resuscitated. 

Seven of the 22 posterior positions necessitated forceps 
delivery and three of these infants were asphyxiated. 

Two premature infants and one with short cord which 
was around the neck required resuscitation. 

The high forceps were used with one case of eclampsia 
and with one case of contracted pelvis. 

Medium forceps were used with one case of eclampsia, 
one case of contracted pelvis with a history of four pre- 
vious labors with forceps, and one case of uterine inertia 
due to extreme diastasis of the recti muscles. 

Low forceps used in six posterior positions and two 
primipara with delay at the perineum. 

There were no infants lost at birth and all the mothers 
left the hospital at the usual time in good condition. 

Two of the mothers had deficiency in the secretion of 
milk. Both were primipara, one 36 years old and the 

88 



















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SCOPOLAMINE-MORPHINE ANAESTHESIA 

other 26. The latter had been deserted by her husband 
after the birth of the baby and the deficiency in milk was 
attributed to the patient's grief and her loss of interest in 
eating. 

One of the patients, primipara, entered the hospital with 
general oedema and urine showing large per cent of albu- 
men. She gave birth to twins, one weighing nearly seven 
pounds and the other nearly eight pounds. She was able 
to nurse both infants and they have gained at the rate 
of half a pound a week, requiring no artificial feeding. 

Another patient, 44 years of age, para IV with history 
of being unable to nurse any of her three children born 
when she was between 28 and 32, was pleased and sur- 
prised to have an abundant supply of milk for her 
'Twilight baby." 

Many of the patients would have shortened the period 
of their convalescence if they had been allowed. 

A young Lithuanian mother gave birth to her first baby 
during the night. She had been in the hospital for several 
days waiting for her labor. The morning after her deliv- 
ery she arose, and as on the previous morning, dressed her- 
self and commenced to make her bed, when the nurse 
discovered her and sent her to bed. 

On another occasion a patient who had been delivered at 
10:00 o'clock p. m., at 5:00 a. m. was found leaving the 

89 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

ward. She was seen by a companion patient and told that 
her baby had been born and she must go back to bed and 
ring for the nurse. 

Four of the patients had normal labors for the first 
time, all of the previous ones being forceps delivery. One 
of them, a Greek woman, had a hard labor, but it termi- 
nated normally after five hours; and her husband expressed 
great enthusiasm for the management of the case, because 
in five other deliveries she had had "pinchers" — as he 
expressed it — used. 

The patient under scopolamine-morphine seems to make 
very little muscular effort in the second stage, when com- 
pared with the patient without this anaesthetic, yet when a 
woman has had five previous labors with forceps delivery 
and then, under this anaesthetic, gives birth to a ten and 
a half pound boy without instrumental assistance, you 
begin to feel that much of the muscular effort exerted by 
the non-anaesthetized patient was not only unnecessary, but 
positively wasted energy. 

It has been suggested that the chief effect of the 
scopolamine-morphine is to produce amnesia, and that the 
pain is not really decreased. We have in a few cases been 
able to demonstrate the value of the anaesthetic as an 
analgesic. 

A young Russian Jewess entered the hospital screaming 

90 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

with pain. She would not sit or lie down or even permit 
an examination. She was given 1/100 grain of scopola- 
mine and y% grain of morphine and twenty minutes after- 
ward allowed the interne to examine her. The cervix was 
fully dilated and the head engaged. At the end of half an 
hour 1/100 grain of scopolamine was given, after which she 
was quiet between pains and complaining only slightly 
during pains. At the end of the next half-hour the third 
dose, 1/100 of scopolamine, was given — after which time 
she made no complaint, but bore down during pains and 
rested with half-closed eyes between pains. The baby was 
delivered one hour after the last dose, during a pain, as is 
our custom with this anaesthesia. There were no lacera- 
tions and the baby was lively. The patient was at no time 
unconscious, and expressed her gratitude at being relieved 
of the pain. 

Many anaesthesia? in multipara are considered unsuc- 
cessful, because the patient seems to live over the experi- 
ences of previous labors and refer those experiences to the 
present labor. This was accidentally discovered by care- 
fully questioning the patients. 

One said that she remembered everything, but most 
vividly the disagreeable tasting medicine given her after 
the baby was born. The facts were that she had had no 

91 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

ergot or any other medicine while in the hospital except the 
injections of scopolamine-morphine. 

Another patient said, with every possible intonation, 
whenever she had a pain, "A little more! A little more!" 
After the labor she thought she knew everything that hap- 
pened and when asked what was most vivid, replied: "Dr. 
Shaffer's telling me to bear down a little more." On 
questioning Dr. Shaffer, who delivered her at a previous 
labor, and who was not able to be present at this labor, 
I found that the patient had at that time been urged 
again and again to bear down. No such suggestion was 
made at this delivery. 

A trained nurse, who was very talkative during the 
delivery and had caused much amusement by ordering 
vegetables, picking out the poor ones, and getting the 
wrong change, gave a most striking example of the effect 
of preconceived ideas. She exclaimed in a frightened 
voice just after the head had been delivered: U A hemor- 
rhage ! A hemorrhage ! Massage the uterus !" When 
conscious the next day she was asked what she remem- 
bered. She said she remembered when the membranes 
ruptured and of course when she had that terrible hemor- 
rhage. As a matter of fact, the membranes did not rup- 
ture, but came down over the head as it was delivered; 
and she lost scarcely a drop of blood. She had, however, 

92 



SCOPOLAMINE-MORPHINE ANAEST HESIA 

as a nurse been with a number of patients who had had 
severe hemorrhages and she feared such an experience for 
herself. This was the explanation of the memory. 

So many of the patients come into the hospital in labor 
that it is difficult to calculate the length of the first stage, 
and I feel that even the length of the second stage is more 
or less imperfectly known, as many patients are examined 
only once and a few enter after the second stage has 
begun. 

I shall therefore not attempt to give statistics, but state 
my opinion — which is that the length of labor is materially 
shortened. This comes from the shortening of the first 
stage, for, although the second stage is lengthened, it is not 
lengthened by more than one or two hours, while the first 
stage is shortened by from two to ten hours. 

No effort is made to draw off the milk or to keep the 
baby from the breast after the delivery under scopolamine- 
morphine anaesthesia and no ill effects have been noted by 
so doing. 

The noisy or excitable patients make a profound im- 
pression on the nurses and physicians and have a tendency 
to dampen the enthusiasm for the anaesthetic. Only eight 
per cent, however, of the patients were noisy, excitable or 
difficult to manage — and would have been probably quite 
as difficult if they had had no scopolamine-morphine. 

93 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Additional doses of morphine were given sixteen patients. 
Three received y$ grain, five received 1/16 grain and 
eight received 1/32 grain. 

The additional doses of morphine are not necessary 
when one can have the proper apparatus for managing 
the case. 

Table II 

TABLE OF DOSAGE 

Successful cases of amnesia and analgesia 70 

Partially successful analgesia and amnesia 26 

Failures in both analgesia and amnesia 4 

Largest dosage given — Morphine 2/8 gr. and 1/32 gr., 

scopolamine 9/100 gr. 
Smallest dosage given — Morphine 1/16 gr., scopolamine 

1/200 gr. 

Cases given 1 dose 6 

Cases given 2 or 3 doses 41 

Cases given 4 doses 25 

Cases given 5 doses 14 

Cases given 6 doses 13 

Cases given 9 doses 1 

The Table of Dosage shows that seventy per cent had 
perfect analgesia and amnesia. Twenty-six per cent had 
either or both the analgesia or amnesia imperfect. The 

94 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

four per cent failures were due to the patients receiving 
only one dose and being delivered before it could take 
effect. 

Many of the cases reported as only partially successful 
are quite as, if not more satisfactory, than those that were 
entirely successful. 

It is encouraging to see that forty-one per cent or nearly 
half of the cases did not require more than three doses, 
while sixty-six per cent did not have more than four doses. 
The largest dosage was morphine 2/8 and 1/32 grains and 
scopolamine 9/100 grain. This was given to a primipara 
with elongated conical cervix, position of baby R O P 
rotated to A, labor twenty-four hours' duration, no lacera- 
tion, no forceps, no hemorrhage. 

In September, 1909, at the Sixteenth International 
Congress at Budapest, I reported a series of operations 
performed on pregnant women under morphine-scopolamine 
anaesthesia. I have since added six cases to this number, 
and present them in Table III. 



95 



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96 




Plate XV. Van Hoosen Method of Deepening Respiration or 
Awakening Patient. 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Although the number of cases here is small, the fact 
that they are not selected and that the operations were 
performed under different conditions in eight different 
hospitals makes it evident that much may be attributed to 
the morphine-scopolamine anaesthesia in preventing interrup- 
tion of pregnancy, because it secures — first, the full physi- 
ological effects of two of the most powerful uterine seda- 
tives for two hours before the time of, during the opera- 
tion, and for twelve to seventy-two hours after the opera- 
tion; second, lessened shock; third, comparative freedom 
from vomiting; fourth, relief from post-operative pain. 
This removes some of the predisposing causes of inter- 
rupted pregnancy. In support of the great value of the 
morphine in threatened abortion, J. M. Baldy reports that 
when he used morphine during or after the operation on 
pregnant women they did not abort in four cases; where he 
did not use any morphine, they aborted. 

One might fear that the hypodermic injections of three- 
fourths grain of morphine and three-one-hundredths of 
scopolamine within two hours' time given to a pregnant 
woman would be injurious to the foetus. That the injec- 
tions are absorbed by the foetus, the experiments of Holz- 
bach prove conclusively. He found that the scopolamine 
was excreted in the urine in the colostrum and in milk for 
the first three days after it was injected; that in a quarter 

97 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

of an hour after the injections were given the mother, the 
drug had passed through the placental circulation and 
appeared in the urine of the new-born child. 

In the adult the most notable effect is on the blood 
pressure, which it increases in seventy per cent of the 
cases. We must look for a similar action in the foetus, and 
although we have no direct means for taking the blood 
pressure in the foetus, my observations on the foetal heart 
have demonstrated to me that the sounds of the foetal 
heart became more audible while the foetus is under the 
scopolamine-morphine anaesthesia. We have, therefore, 
the stimulation of the circulation as the most prominent 
action of the anaesthetic on the foetus, and the foetus could 
probably survive doses of the scopolamine-morphine that 
would prove fatal to the mother. 

I have reported these few cases hoping to help establish 
confidence in this anaesthesia for pregnant women under- 
going surgical operations or examinations, and to empha- 
size these points: 

1st. That amounts injected sufficient to produce surgi- 
cal anaesthesia will not endanger the life or retard the 
development of the foetus. 

2nd. That this anaesthetic tends to prevent interruption 
of pregnancy. 

3rd. That the increased strength of the foetal heart 

98 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

under this anaesthetic may aid us in making a differential 
diagnosis of pregnancy. 

In abortion the effect of the anaesthesia is ideal, for it 
will either prevent abortion if there is any possibility of 
doing so, or if the abortion is inevitable it will not only 
relieve all pain, but will accomplish that much desired 
result, the expelling of the entire ovum as a whole from 
the uterus, so that curettage or any manipulations are 
unnecessary. 

The administration of the anaesthetic is the same in 
abortion or premature labor as in labor at full term. 
These advantages may be expected in giving obstetrical 
patients "Twilight Sleep": 

1. The relaxation of the soft parts (especially sphinc- 
ters) and the absence of acute pain have a tendency to 
shorten the first stage of labor (probably by one-half), 
thus conserving the strength of the mother. 

2. The relaxation of the soft parts and absence of 
acute pain make the second stage more manageable, espe- 
cially the delivery of the head. Under "Twilight Sleep" 
most women practically deliver themselves without lacer- 
ation. 

3. The secretion of milk is better maintained because 
of the absence of shock during labor and fatigue following 

99 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

labor. The "Twilight Sleep" furnishes an anoci for labor, 
with all its marvelous benefits. 

4. Hemorrhage is a rare occurrence. In only three 
cases out of fifty was there enough blood to measure or 
estimate. 

5. The period of convalescence may be shortened on 
account of the rapid involution of the uterus and normal 
condition of the mother; both direct results of anoci. 

6. If necessary to do version or apply forceps, no 
chloroform or ether is necessary, and even repairs may be 
made without the patient's remembering it. 

7. The effect of scopolamine is to drive all the blood 
into the capillaries, to increase the activity of the kidneys, 
stimulating elimination and relieving nervous irritability, 
thus aiding in the management of puerperal convulsions 
and toxemias. 

8. In abnormal deliveries the child stands a better 
chance for life on account of increased action of the heart 
induced by the absorption of scopolamine. The effect on 
the heart was beautifully demonstrated recently in one case 
of breech delivery, where the child was asphyxiated, but the 
heart-beat was so strong that it raised and lowered the 
handle of the hemostat that was lying on the chest of the 
child. 

To sum up : The lessening of hemorrhage, the decrease 

100 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

in number of lacerations, the rapid convalescence, the 
increased secretion of milk, all make for infant welfare. 

"Twilight Sleep" should be used for its advantage to 
the child: To give it a better chance for life at the time 
of delivery; a better chance to have breast-feeding; a better 
chance to have a strong, normal mother; a better chance 
to escape in its after-life the results from the use of high 
forceps and improper feeding. 

Scopolamine-morphine, with its wonderful anoci prop- 
erties, solves the problems of child-bearing and rearing for 
the highly organized mothers of modern civilization, for it 
virtually uncouples the brain from the spinal cord, and for 
the time being leaves the woman a good animal to bear 
her offspring as easily as any other animal. It is the greatest 
boon the Twentieth Century could give to women. 



101 




CHAPTER VIII 

The Mental Effects of Twilight Sleep 

preliminary report, with suggested technique 
for research 

BY ELISABETH ROSS SHAW, 
Author of "Mental Measurement" 

|HE thoroughly modern physician is accustomed 
to considering the mind and body of his patient 
as one indivisible whole, and constantly makes 
use of encouragement, persuasion and other sane 
and conservative forms of mental treatment. 

To such a physician, a drug which not only inhibits 
mental phenomena, as all anaesthetics do, but which some- 
times produces temporary mental reactions of considerable 
variety, ought not to seem wholly unnatural and uncanny. 
The fact that this drug produces its best effects when used 
in conjunction with persuasion and encouragement should 
not cause irritability in any physician accustomed to the 
wise and efficient handling of human nature. 

In the following descriptions of actual events during 
scopolamine-morphine anaesthesia, the reader's attention 
will first be attracted to the striking contrasts shown in 
various cases. Only later, after thoughtful analysis, will 
resemblances become apparent. This variety of reaction 

103 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

occurs even when the identity of external stimulus is con- 
trolled with laboratory precision; hence the inference seems 
justifiable that the variation of effect has its roots in 
individual human nature. Therefore, the problems in- 
volved belong in the realm of physiological psychology. 

No tabulation of either contrasts or resemblances 
between individual patients will be attempted here, as it is 
doubtful if a tabulation covering less than a thousand cases 
would be scientifically valid. The observations are noted 
in chronological order without any effort to draw psycho- 
logical conclusions. No claim is made that the cases here 
recorded are typical; they were selected at random, and 
happen to include some extreme illustrations of great mus- 
cular activity and complete passivity, of total amnesia and 
almost complete recollection of events. 

The chief purpose of this brief preliminary report is to 
urge the adoption of a uniform and convenient psychologi- 
cal technique for the study of this complex problem, so that 
the labors of different investigators can be correlated, and 
conclusions eventually drawn from the combined experience 
of numerous experts. Research work demands not only 
infinite accuracy and patience, but the most impersonal 
attitude of mind, and final conclusions will be scientific in 
proportion as their authorship is as composite as that of 
a folk song. 

104 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

The technique here suggested is of composite authorship 
and of purely clinical origin. *It has been widely used 
for psychiatric, pedagogic, military and vocational pur- 
poses. Its chief advantage is its utter simplicity. Unfor- 
tunately, this simplicity does not extend to the interpreta- 
tion of the results. A specially trained nurse or interne, 
with the help of a good stenographer, could do the actual 
mechanical labor of testing and recording; but only an 
expert should be trusted to analyze and interpret the 
phenomena of consciousness or subconsciousness revealed 
in the records. This fact should be most earnestly empha- 
sized: this technique is simple and easy only for the 
patient and for the technical assistant, never for the inter- 
preting psychologist on whom the real responsibility of 
the experiment rests. Unquestionably this interpreter 
should have taken the anaesthetic himself, preferably more 
than once, in order to have the introspective basis for 
interpreting the mental effects of the chief forms of dosage 
in common use. Otherwise he would be like a man born 
blind, discoursing learnedly of color sensations. 

In order to avoid misunderstanding, it will be well for 



*Note: For further information concerning these and other methods in 
use by Professor Robert Sommer in the Klinik fuer psychische und nervose 
Krankheiten in the University of Giessen, see the writer's booklet entitled 
"Mental Measurement."— A. C. McClurg & Co. 

105 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

the reader to be prepared for a few of the glaring para- 
doxes which he will meet in the following pages : 

1. The patient who showed the greatest degree of 
muscular activity during the period of anaesthesia remem- 
bered comparatively little afterward. (See Case A.) 

2. The patient who was most talkative remembered 
nothing. (Case S, not reported here.) 

3. A patient who was remarkably silent and docile 
remembered far more than any of the others. (Case F, not 
reported here.) 

4. A patient who had the bravery to claim complete 
peace of mind, really had such a horror of the knife that 
the drug could not produce its full effect. The same 
patient at a second, far more serious, operation slept 
soundly without chloroform or ether, because she was 
then truly free from anxiety. (See Case C.) 

5. In the introspective testimony of the writer, the 
degree of consciousness does not coincide with the clear- 
ness nor coherence of speech. (See Case X.) 

Description of Case A — (Obstetric) 

A Russian Jewess, aged 32, third confinement, excep- 
tionally bright mentally, as shown by psychologic tests 
which lack of space forbids our reproducing here, came to 

106 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

the hospital last June suffering from unhealed lacerations 
caused by the birth of her second child nine years previous, 
was discovered to be pregnant and operations on the lacer- 
ations deferred. 

The course of this pregnancy had been under medical 
oversight and the child is believed to be one month over- 
due. The mother knows that a few days after delivery 
she must be operated upon. During the first Orientation 
test on November 23rd, she says: "Well, I am thinking 
of this (the lacerations) all the time 'cause I have to be 
'tended to." Tells of the death of her eldest child and 
adds philosophically: "It seems like if anybody has to go, 
they go." Seems to be patiently resigned and free from 
anxiety with regard to the coming events. The birth had 
then been expected daily for two weeks, yet she showed 
no sign of suspense. 

On December 7, 1914, at 1:30 p. m., the patient came 
to the hospital, having "slight backache." The membranes 
had broken that morning at 4 a. m. 

The following doses were given: 

4:45 p. m., scopolamine grs. 1/100, morphine grs. 1/8. 

5 :15, 5 :45 and 6:15, scopolamine grs. 1/100. 

The tests began at 6:30, fifteen minutes after the fourth 
dose of scopolamine. At that time she was having severe 

107 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

pains almost continuously. Her mind seemed perfectly 
clear. She spoke excellent English and failed in nothing 
but naming the month, which might have been due to 
preoccupation at the moment, or to the onset of motor 
aphasia. At Q. 4 she showed what might have been slight 
paralogia, at Q. 17 she suddenly dropped into a foreign 
pronunciation of English and in the next sentence broke out 
in a Yiddish exclamation. This was the first foreign word 
she had used at all. At the end of this test she was sleepy, 
but trustful and good natured, in spite of the pain. 

At 6:59, after only an eight-minute interval, this test 
was repeated. This was forty-four minutes after the 
fourth dose. So rapidly had the mental effect progressed 
that when asked: "How old are you?" she answered the 
age of her child. (Paralogia.) In Q. 4 she showed inability 
to remember the question more than a moment. At Q. 5 
she does not reply, but wails, and throws her pillow back 
of the bed, being evidently unconscious of what she is 
doing. She answers Q. 6 rationally, but gives no reply to 
same, rubs hands together, then stands up on the bed 
with an exclamation of pain in Yiddish. She staggers as 
if drunk, shows great muscular inco-ordination. Her an- 
swer to Q. 8 seems to show some interruption of the time- 
sense between 4 and 6 o'clock. At this moment the 

108 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

second stage of labor began with its characteristic sensa- 
tions in the pelvis, so she asks to leave the room. This 
idea constitutes a powerful auto-suggestion, which com- 
pletely rules her conduct during the following hour and 
a half of unconsciousness. She answers Q. 9 correctly in 
English, then exclaims in Yiddish. At Q. 10 seems to be 
the onset of auditory aphasia; she looks bewildered and 
asks: u What do you mean?" but answers correctly after 
the question has been repeated; Q. 1 1 brought no response, 
whether because of aphasia or genuine sleep could not be 
determined; Q. 12 was followed by a few irrelevant Yiddish 
words concerning her own sensations, and by a distinctly 
articulated English sentence showing hallucinations of 
paper on stove, after Q. 13 she talks Yiddish rapidly and 
mumblingly partly concerning the same idea of paper. 
From this moment she becomes violently active, thrashes 
around constantly trying to climb out of the crib. She does 
not seem emotionally excited, but good naturedly deter- 
mined to act out the last idea that was in her mind before 
she lost consciousness. At 7:12 p. m. a blanket is laid 
over the top of the crib and strongly pinned on, but she 
breaks the fastenings, so it has to be held in place by 
several people. She moans softly, says: "Oh, Weh," 
many times, mutters in Yiddish unintelligibly, even to one 

109 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

who understands the language. Much of this time she is 
quite silent, pushing upward perseveringly against the 
blanket. Speaks no English until 7 :24, when she suddenly 
laughs aloud and says with perfect articulation, "It's hot in 
here." 

The blanket is immediately taken off. After a short 
interval she stands up on the bed again and resists silently 
but determinedly while three physicians steady her and 
persuade her to lie down. Her eyes are open, but she 
shows no sign of consciousness. After this she lies down, 
and sleeps at frequent intervals, but only a minute at a 
time. The rest of the time she pushes strongly but silently 
at the blanket or at the arms of the physicians who hold 
her by the sleeves. Her face is wholly expressionless, and 
she makes no response to her name, no matter how loudly 
called. 

At 8:16 the bed is moved under the light and the crib 
curtains removed. She speaks a few disjointed phrases in 
English and Yiddish. Once cried out: "Momie, Momie!" 

At 8 :33 mumbles, "That's what I thought." 

At 8:50 the doctor calls her repeatedly, loudly. Her 
eyes are open, but she makes no sign of consciousness. She 
lies quietly with her feet in the stirrups, seems to use her 
muscles efficiently, without haste or any unnecessary waste 
of effort. Face expressionless as that of a somnambulist. 

110 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

In fact, the appearance of the case, from 7:12 onward, had 
been characteristically somnambulistic. Her movements 
had not been at random, but obsessed by one definite pur- 
pose, wholly uninhibited by any other ideas. 

At 9 :20 she gave birth to a plump boy. Delivery nor- 
mal, without hemorrhage or laceration. 

At 10:40, having slept soundly meanwhile, we found her 
awake, bright-eyed and rosy. The following conversation 
occurs. Doctor V. H. : "Well, how do you feel about 
your confinement?" Patient: "Oh, ma'am, I wish it was 
over." Doctor V. H. : "Are you sure your baby hasn't 
come?" Patient: "Oh, no, it hasn't come." (Positive, 
smiling.) Doctor V. H. : "Feel down there and see." 
Patient: "Oh, yes; I can feel my baby there. I can feel 
it move. They are just joking me." Doctor V. H. : 
"Have you had any pain since 4:00 o'clock?" Patient: 
"I don't know, perhaps I slept a little. Sometimes I think 
I have had pain." 

The following morning at 10:05, when asked if she 
could remember, she laughed and said: "I really can't 
remember. I started to get sick about 4:00 o'clock. That's 
all I can remember." Persistent questioning and urging 
brought out a few apparent memories as to persons present, 
but as she mentioned only those whom she had doubtless 
expected to be present, these were not wholly convincing, 

ill 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

especially as she made some mistakes. Among these, how- 
ever, were two memories which were unquestionably real; 
she said: "I remember the way they laughed at me." 
E. R. S. : "Did it hurt your feelings?" P. : "Oh, no. 
Probably if I'd hear anybody that way Fd laugh. I don't 
know what I was saying." "What is your next memory?" 
P. : "I don't know whether I was dreaming, but I think I 
remember how I wanted to get out in the other room. May 
be I dreamed it. After I fell asleep I didn't know anything 
about it." "What did you mean when you said 'Momie'?" 
P. : (with great surprise) "Did I say that. My mudder's 
been dead twenty years. I was a little child then — " (Sighs, 
rubs palms together.) 



Description of Case C — (Operative) 

A cultured American lady, age 63, of fine intelligence 
and habitual optimism, determined to be brave, but secretly 
feeling a horror of the hospital. 

This case affords a striking illustration of the influence 
of emotion on the mental effects of the anaesthetic, as two 
operations were performed when the patient was in totally 
different moods. 

112 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

On January 2, 1915, occurred the first operation, which 
was little more than a mere examination lasting seven or 
eight minutes. This examination proved the diagnosis of 
uterine carcinoma. 

The patient, having expected the removal of a tumor at 
this first operation, apparently stayed awake in spite of the 
drug. She spoke distinctly, using exclamations expressive 
of the most extreme pain. Notwithstanding this, a moment 
later she claimed to feel "lovely" and during the operation 
her pulse decreased from 120 to 100. This was followed 
by complete amnesia. 

The second operation, on January 6, was a pan-hysterec- 
tomy. The cancer proved to be squamous-celled, and one 
ovary was enormously swollen and filled with pus. The 
operation lasted over two hours, during which time the 
patient slept deeply with a peaceful expression. At no time 
during the operation did the knife appear to produce any 
effect on her nervous system. The few slight moans and 
twitchings recorded occurred when gauze was pressed on 
the tissues to dry them, and when gauze packing was in- 
serted or removed. The healthy color and perfectly nat- 
ural expression of her face throughout the experience was 
like natural sleep. The record which follows includes 
every variation from absolute peace which occurred during 
the operation. 

113 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Needless to say, this was followed by complete forget- 
fulness. The patient is making an excellent recovery. 

FIRST OPERATION, SATURDAY, JANUARY 2, 1915 
{In operating room) 

11:20 a. m. (Pulse 120.) First operation begins. 

11:21 a. m. "Oh, dear me (mumbles). (Patient 
cringes with expectation of pain.) "Yes, he comes. Oh, 
dear me. Please let me go. I can't stand that." (Moans.) 
"Oh, oh, my Lord." 

11:25 a. m. "Oh, my! that hurts so." (Curettage.) 
"Oh, people, I never imagined — Oh, dear." 

11:30 a. m. Operation finished. 

11:30 a. m. Doctor V. H. : "How do you feel?" 
Patient: "Lovely." Doctor V. H. : "Have you any 
pain?" Patient: "A little at times." Doctor V. H. : 
"Have you had any pain this morning?" Patient: "Just 
a little." (Pulse 100.) 

11:32 a. m. Doctor V. H.: "Where are you now?" 
Patient: "In the kitchen." Doctor V. H. : "Where are 
you going?" Patient: "Well, I am afraid I'll mix the 
nurse up because I have such a horror of the hospital." 
MEMORIES AFTER THE FIRST OPERATION 

Tuesday, January 5, 1915, 2:55 p. m. (three days after 
first operation). Question: "What have people told 

114 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

you?" Answer: "The only thing is the nurse said my 
daughter stood in the hall with tears rolling down her face 
when I was taken upstairs. I remember the nurse put a 
nightgown and stockings on me and gave me a hypo in my 
left arm and I remember she gave me another hypo in my 
right arm. Then one of the doctors came and asked me 
if I was asleep yet and I said, 'No, I'm not asleep.' Then 
they gave me another hypo in the right arm. I don't 
remember anything after that." Question: "Where were 
you when you woke up?" Answer: "Right here. I 
didn't know that I had been taken from this bed." 

SECOND OPERATION, WEDNESDAY, JANUARY 6, 1915 
{In operating room) 

8:10 a. m. (Operation begins with loosening of the 
vagina.) (A few slight twitchings of mouth, but most of 
the time complete repose.) 

9:00 o'clock. (Abdominal section begins.) Perfect 
facial repose, breath puffs the lips out slightly. 

9 :07 a. m. Right corner of mouth twitches, a few slight 
moans as gauze packing is inserted. Moans increase. 

9:12 a.m. Slight attempt at articulation. Face natural, 
slightly flushed. 

9:21 a. m. One twitch of mouth. Slight moan, as 
gauze packing is inserted for a moment. 

115 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

9:25, 9:27, 9:35, same as 9:21. Moans always when 
gauze is pressed on tissues to wipe away blood. 

9 :45 a. m. Mouth slightly open, tongue moves, attempt 
at articulation, as the whole loosened tissue is lifted. "La, 
La m-m-m — " 

9:47 a. m. (Utero sacral ligaments severed.) Immedi- 
ately snores softly. 

10:00 a. m. Moan. 

10:04 a. m. Catches breath, tries to articulate. 

10:07 a. m. Catches breath, tries to articulate. 

10:08 a.m. "Oh, my!" Tries to articulate. 

10:12 a. m. (Beginning salt solution transfusion.) 

10:21 a. m. Packing removed. Moan. Sleeps peace- 
fully while the incision is closed. 

10:30 a. m. Operation finished. 

MEMORIES AFTER THE SECOND OPERATION 

Monday, January 11, 1915, 11:30 a. m. (Five days 
after second operation.) 

E. R. S.: "What do you remember?" Patient: "Noth- 
ing at all. I have slept most of the time this week." 
E. R. S. : "Do you remember being taken upstairs?" 
Patient: "No, I can not remember being out of this 
room." 



116 



SCOPOLAMINE-MORPHINE ANAESTHESIA 



Description of Case X 

On January 8, 1915, Dr. Van Hoosen and her assistants 
put the writer of this chapter under scopolamine-morphine 
anaesthesia as a psychological experiment. The full dosage 
was given as if a major operation were to be performed, 
and then the writer was forced to talk almost constantly 
for several hours, a full stenographic record being kept as 
a basis for further study of the mental functioning thus 
expressed. 

We were led to make this experiment as the only logical 
next step in our study of the mental effects of the drug, 
because of the bewildering variety of effects produced in 
the bona fide patients, and the insuperable difficulties in the 
way of interpreting these effects. It therefore appeared 
necessary, first, to reduce the problem to its lowest terms 
by eliminating some of the most variable factors, such as 
illness, pain and anxiety; and second, to furnish an intro- 
spective basis for interpretation. 

In the following description the separate records of the 
attending physicians and psychologists have been combined 
with the stenographic record in chronological order. The 
preliminary Orientation test, taken in the train on the way 
to the hospital, was for the purpose of discovering the 
mental attitude of the examinee immediately before the 

117 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

experience. It will be apparent that the mood was opti- 
mistic, and that the humor of the situation was keeenly 
appreciated. 

TEST I 
On the train going to the hospital. 
Name — Shaw, E. R. 

Week Day — Friday 
Date — January 8, 1915. Hour — 1:30 p. m. 

(Seconds) 

1. What is your name? (1.0) Elisabeth, Elspeth, 

Betsey and Bess (bantering tone). 

2. When is your birthday? (.8) Independence Day 

(bantering tone). 

3. Where is your home? (1.0) Evanston — my parish 

(bantering tone). 

4. What year is this? (1.2) 1914— 'taint neither! 

(bantering tone). 

5. What month is this? (.7) January, 1915 (slightly 

triumphant tone). 

6. What day of the month is today? (1.5) 8th. I 

looked it up on purpose (bantering tone). 

7. What day of the week is today? (.4) Friday. I 

can just see that calendar! 

8. How long have you been here? (1.5) Since the 

train started — I was mentally trying to figure — 

118 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

9. In what city are you now? (1.4) Chicago (nods). 

10. Who brought you here? (2.4) Dr. Van Hoosen. 

11. What kind of a house is this? (1.6) (laughs) 

Movable house. 

12. Who are the people in this house? (2.4) Friends 

and strangers — the former being more important. 

13. Who am I? (1.5) Yourself — spelled with a capital 

Y. 

14. Where were you a week ago? (4.2) (frowns) At 

the hospital. No, I was on this train going to 
the hospital. 

15. Where were you a month ago? (2.4) In Evanston 

— that's pure guesswork. 

16. Where were you last Christmas? (4.2) (frowns) 

At Uncle Al's. 

17. What did you get for Christmas presents? (6.6) (tilts 

face, makes gestures signifying helplessness) I 
dunno. The only one I really liked was, I was 
going to say a Bridget apron, but I liked my 
Chinese gown, too — and a string of Venetian 
beads, but I got that by a process of reason — 
remembered the person that gave them to me. 

18. Are you sad? (5.0) The top layer of me is feeling 

very humorous, the under layers get less comforta- 
ble as I go down. 

119 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

19. Are you sick? (1.4) No. 

20. Why do I ask you all this? (2.6) (grins) Pure 

diviltry. 

2:40 p. m. reflexes January 8, 1915. 

/. Pupils Before Dosage 

Size Same 
Light with electric light * r Accommodation Crossed reflex 

at arm's length 

R. Normal 4 3J^ Normal Normal 

L. Normal 4 3J4 Normal Normal 

//. Patellar 

R. Normal reflex. 
L. Normal reflex. 

///. Plantar 

R. No response to stimuli. 
L. No response to stimuli. 

3:00 p. m. Temperature 98.4, Pulse 84, Respiration 20. 
(Says, "I am so comfortable.") 
First Hypodermic 

3:00 p. m. % g r - morphine, 1/100 gr. scopolamine. 
3 :09 p. m. Beginning of 

TEST II 

This is a test of ability to memorize 15 pairs of words, 
some logically connected and some illogically, after the 
method devised by Professor Ranschburg. The following 

120 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

list was substituted for the Ranschburg list, because the 
examinee was already familiar with the original. 

school — pupil 
son — daughter 
sound — ear 

Repeated all of these, and said, "My eyes are beginning 
to get very blurred, as if I had atropin in them." 

land — water 
horse — carriage 
wheel — axle 
cat — dog 
rise — fall 
hat — bonnet 

Repeated these except wheel — axle. She says, "There 
ought to be another pair." She remembered these two 
also a moment later when asked by A. T., "What did I 
say after wheel?" 

snake — fiddle 

hand — mountain 

door — box 

apron — courtyard 

paste — canal 

milk — paper 

Says, "I want to start with land — water, and I know that 
won't do. I want to start with fish — thunder and I know 
that won't do." 

121 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

(Note: The words fish — thunder belong to the original 
Ranschburg test.) (Then after a pause of ten seconds, 
repeats all the words except hand — mountain.) Says, 
"That's all I can remember. My mouth is getting very 
dry and my eyes feel so funny." 

A. T. : "What did I say after hand?" 

E. R. S.: (after 3.2 seconds) Mountain! 

"What did I say after paste?" 

(After 2.4 seconds) Canal. Oh, that's one I forgot. 
Canal — I almost said u map." 

(Test interrupted for 10 or 15 minutes by taking of 
reflexes.) Says, "Oh, I am dizzy, and things look so 
funny." (Rubs hands across mouth.) 



3:29 p. m. 

/. Pupils 

Light Size 

with electric light 
at arm's length 
R. Normal 4 

L. Normal 4 



REFLEXES 



Same 
At 1 ft. 



3/ 2 
3/ 2 



Accommodation 

Normal 
Normal 



Crossed 
reflex 

Normal 
Normal 



//. Patellar 

R. Present normal. 
L. Present normal. 

///. Plantar 

R. No response to stimuli. 
L. No response to stimuli. 



122 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

3 :36 p. m. 

E. R. S. : Let me give you my remote first. Just had 
it on my tongue's end — I can just see boys and girls there, 
pupils in school, in the academy, and that fitted right in 
with son and daughter. Can you hear me? Am I talking 
plainly enough? 

Well, you see that made the first two pairs, I mean the 
first. Then the son and daughter would be talked to by 
the teacher, that would be sound — voice. I saw every- 
thing in the school; I saw the pupils sitting in it, and I saw 
the son and daughter. 

(Asks if she can have all the water she wants, and is 
granted a reasonable amount.) 

My eyes feel so funny. (Asks us to watch left eyelid.) 
(Later this eyelid drooped.) Mouth tastes funny. Second 
list was what the pupil studied. Land and water is geog- 
raphy; horse — carriage is transportation, so it belongs in 
physical geography; rise — fall of the Roman Empire 
would be history. Cat — dog would belong to zoology. I 
can see all these things and also see pupils studying out of 
these books. Wheel — axle worried me because it wasn't 
any special subject of study. I would be so glad of an 
excuse to stop talking. Don't know what came after 
horse — carriage, but am sure pupils were studying. I 
know. They were studying domestic science and making 

123 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

hats and bonnets. Is that all of that list? I had a feeling 
the list wasn't long enough. That's too much for me. 
I think there was another subject of study, but don't know 
what. 

Snake — fiddle. I knew a student from California study- 
ing music in Munich. He became so alcoholic he couldn't 
succeed at anything. That fitted in with snake — fiddle. 
Munich boys do lots of mountain climbing. Association. 
Then I came right here, and thought of this door and that 
box-like piece of furniture. Apron — courtyard was this 
doctor's apron and the courtyard of the hospital. (Hesi- 
tates.) Think it was connected with us here somehow. 
Was just repeating "apron — courtyard" to see if that 
would bring up the next thing. I connected it here with 
the hospital. That's all I know. Now you can begin. 
I saw all those things very distinctly. Better ask me how. 

A. T. : How did you remember paste — canal? 

Paste — canal, but that couldn't connect with apron — 
courtyard here. I say my map of Idaho. It's torn and 
I had to paste it. (Thinks of irrigation canals there, but 
doesn't mention them until later.) 

Milk — paper. That was all connected with Idaho. I 
pasted the map and then rode past the place where we buy 
our milk, to Hollister, where I bought a paper. 

That was vivid. I feel myself (stops). 

124 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

3 :30 p. m. Pulse 84. 

My tongue is getting thicker all the time. I feel as if 
my body were going to sleep on me and the rest of me 
were staying awake inside. (Starts for the next room.) 
Come along with me and see if I snagger (means stagger). 
(When she came back she went on:) 

I'm so limp. How funny. Doesn't feel like me. Thank 
you. (Tells about A. T.'s illness and tucking in her 
"toots.") 

TEST III 

3 :42 p. m. 

Never felt so lazy in my life. 

Now I am going to tell you a story to see how well you 
can remember. I want you to listen carefully and when 
I have finished I shall ask you to tell it to me. 

"A mother heard her two little hoys quarreling and 
asked the elder, 'What was the trouble V 'Willie is crying 
because I am eating my apple and not giving him any! 
replied James. 'Is his apple all eatenf inquired the 
mother. 'Yes, and he cried while I was eating that, too.' ' 

Oh! (Laughs heartily and coughs.) 

"A mother heard her two little boys quarreling. What 
is the matter, she asked of the elder. Willie is crying be- 
cause I am eating my apple. But didn't Willie have an 
apple? Yes, said James; he cried while I was eating that 

one, too." 

125 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Any more? That's a dandy story. That's all I remem- 
ber. 

Now I am going to ask you some questions to help you 
remember more about this story. What is this story about? 
(1.2 sec.) A mother and her two children quarreling; 
the elder quarreling. 

Who quarreled? (1.4) The two boys. 

Who came to settle the quarrel? (1.2) The mother. 
She came, but she may not have come for that purpose. 

How many children were there? (.4) Two. Willie 
and James. 

What was the elder y s name? (1.0) James. 

How old was he? (3.0) Doesn't tell. 

What was the younger's name? (1.2) (Mumbles) 
Willie. 

How old was he? (1.5) Doesn't tell. 

What was the quarrel about? (2.4) Two apples which 
the elder one ate. 

How many apples were there? (1.0) Two. (Started 
to say something more and didn't.) 

Were the apples eaten? (1.6) By James, yes. 

Who ate the first apple? (1.5) James. 

Who ate the second apple? (.8) James. 

Did somebody cry? (2.2) Willie cried. 

Why did he cry? (1.7) Because he didn't get any. 
Are you writing it in longhand? 

126 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

How much candy was there? (2.3) Not any candy; 
it was apples. 

Who ate the candy? (1.2) (Sleepy tone.) Nobody. 
There wasn't any. 

What did the mother do? (3.0) It doesn't say. (Very 
sleepy tone, a little thick.) 

Now I am going to tell you the story again and you can 
tell me anything you forgot or answered wrong. 

(Story repeated.) 

I left out that the mother heard them quarreling and 
that she asked the elder one a question. 

Anything else? 

Not that I remember. (Very sleepy.) Better take a 
piece of paper and wrap it round that electric light so it 
won't hurt your eyes. 

TEST IV WEIGHTS 

Test performed slowly and languidly, but correctly. 
Says: "My hands are so heavy; whichever weight my left 
hand touches seems heavier." 

(Lifts her hands to show that she was through with 
the weights and that we could take them away. Covers up 
hands with blanket.) 

E. R. S. : "My mouth feels so funny." (Rouses herself 
to meet Mrs. H. and Mrs. G., a friend who speaks Chi- 

127 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

nese.) Asked if she is feeling uncomfortable, says: u Oh, 
no; it's more fun than a little." After being introduced to 
Mrs. H., repeats her name. (Another dose is given.) 
"This is my second dose." (Raises her sleeve herself.) 
"Is it alcohol? I always wondered." (To Mrs. G.) 
"Just a little hypo needle. It doesn't hurt a bit. It must 
be a very fine needle." (Smiles and then explains to 
Mrs. G.) "They are going to give me a psychological 
test." (Explains to Mrs. G. and spells scopolamine, saying 
it is used in Freiberg and Giessen. Talks quite a few 
minutes, explaining how Dr. Van Hoosen does.) 

4:00 p. m. Second dose given. Morphine %. gr., 
scopolamine 1/100 gr. 

(Mrs. G. enters. E. R. S. recognizes and greets her. 
Mrs. G. introduces her sister, Mrs. H.) 

TEST v 
4:00-4:05 p. m. Second Test of Orientation. 

(During this test examinee lay most of the time with 
eyes closed. Spoke with an evident effort, but with perfect 
coherence.) 

1. What is your name? (2.2 sec.) Elisabeth Shaw. 

2. When is your birthday? (1.2) Fourth of July. 

3. How old are you? (1.2) Thirty-nine. 

4. Where is your home? (.8) Evanston. 

128 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

5. What year is this? (1.0) 1915. 

6. What month is this? (.8) January. (Voice trails 

away.) 

7. What day of the month is today? (1.2) Eighth. 

8. What day of the week is today? (.8) Friday. 

9. How long have you been here? (2.2) About an 

hour. (Hesitates.) (Really two hours.) 

In what city are you now? (1.0) Chicago. 

In what kind of a house are you? (.7) Hospital. 

Who brought you here? (1.8) You and Mrs. B. 
did. (Correct.) 

Who are the people in this house? (1.0) Doctors, 
nurses and patients. 

Who am I? (2.4) You're my psychologist. 

Where were you a week ago? (2.8) Here, at the 
hospital, I think; yes. (Retrospective tone.) 

Where were you a month ago? (1.8) I think I was 
in Evanston. 

Where were you a year ago on Christmas? (1.7) 
Uncle Albert's house. 

What did you get for Christmas presents? ( 2 ) Um — 
awfully hard to remember. An apron, and I got 
this (pointing to Chinese gown which she is wear- 
ing) . Uncle Frank brought each of his nieces one 
from China. I don't remember. A string of 

129 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

beads; that little box of pins from Mrs. R. I can 
only remember by thinking of separate people {any 
more?) Yes, a good deal more, but I can't think 
of it. 

19. Are you sad? (1.6) No. I am having the "time 

of me life !" I am wondering what would happen 
if — Oh, dear, how they would howl! 

20. Are you sick? (1.8) No. (Chuckling.) 

21. Why do I ask you all this? (1.5) (Laughs.) To 

see how well the medicine is working. Is that all? 
(To Mrs. G.) This morning was thinking about you 
while I was mending a stocking. It was just before Mrs. 
B. came. The point was that my mind was very relaxed. 
I mean I wasn't thinking about my work. Suddenly the 
Chinese "Now I lay me" came to me. (Repeats "Now I 
lay me" and the Lord's Prayer in Chinese.) 

TEST VI 

4:10 p. m. Pulse 92. 
4:12 p. m. Test VI. 

E. R. S. : Am just so relaxed and comfortable, delicious. 

A. T. / want you to read this over to yourself carefully 
once and when you have finished, give the paper back to 
vie. (A typewritten copy of the following anecdote was 
handed to E. R. S., which she read with some difficulty.) 

130 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

"A package of silverware valued at $25.00 was brought 
to the police station yesterday by an Italian named Mor- 
rison of North State Street. He said that the package was 
found beneath a sidewalk at the rear of his house. The 
silver was marked Messenger." 

Italians aren't named Morrison. I read part of that 
story twice. 

Now tell me the story that you read. 

This morning a package full of silverware was brought 
to somebody on North State Street by a negro named Mor- 
rison and the package was valued at $25.00. And the 
negro said he found it under the sidewalk in the rear of his 
house. And the package was marked "messenger." That's 
all I remember. (Very thick speech in two places.) 

When am I going to get my third dose? I only had 
one. No, I have had two, one in each arm. 

When did you have your third one? I haven't had that 
yet. Are you going to ask me any cross-questions on that 
story? Gee, I am glad I am through the thing. (Turns 
to Mrs. G.) I wonder if I could have said that Lord's 
Prayer before. Quite likely. I haven't thought of that 
"Now I lay me" before for ages. Isn't it interesting? 



131 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

TEST VII MEMORY OF CHILDHOOD'S LANGUAGE 

Now suppose I tell you all the Chinese I can think of 
and then maybe after a while I can tell you more then than 
I can think of now. 

I have just proved that I know the Lord's Prayer. Mrs. 
G. begins quoting a Chinese song and says she doesn't 
know the next line and E. R. S. gives it. She sings with 
Mrs. G. a Buddhist chant. It was suggested that her 
mother had had something to do with this, but E. R. S. 
thinks Mrs. Nevius. Then tries to sing another tune and 
explains that her mother had adapted it. Sings words to 
"Jesus Loves Me" in Chinese. Mrs. G. asks what swe 
da mun means (Who is at the door?). E. R. S. says, "I 
don't quite get the meaning." As soon as Mrs. G. hummed 
a tune, E. R. S. got the words correctly. 

E. R. S. : Mouth is awfully dry, and I can't get my left 
eye open without a great deal of trouble. I had a hand- 
kerchief when I first came. 

I am terribly sleepy, but I am going to fight it. (Shows 
handkerchief to nurses, to Mrs. G. and to me and explains 
that "Bessie," embroidered there, is her baby name.) 

I wish I had not taken the drink of water. (Says after- 
wards that she felt as if she might easily become nause- 
ated.) 



132 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Then talks more Chinese. Repeats "Home, Sweet 
Home," and "Yin Yin shin li," same words to two dif- 
ferent tunes. Says that she remembers the word pao-shin-ti 
— that means postman. Thinks that is about all the 
Chinese she remembers. 

E. R. S. starts singing in Chinese, "I am so glad that 
my Father in Heaven tells of His love in the book He has 
given." 

Mrs. G. : And "Precious Jewels" do you know that? 
(E. R. S. looked over on the wrong side for Mrs. G., to 
the place where she had been sitting.) 

What time is it, about 4:30? (It was 4:35.) 

What was your shing? Isn't that the name? Oh, I've 
almost forgotten. My name was Shaw Bessie (thick tone). 
Can you get the proper Chinese answer? I don't know 
anything except Shaw Bessie. It's a whole lot of stuff about 
your being the most humble servant. It takes an hour to 
say "How do you do?" and two hours to say "Good-bye." 
What is the polite answer? I don't know, except that you've 
got to have a general feeling that you're a worm in the 
dust. Humble? Don't know what it is. Goo-niang-gin- 
sheng. That would be an unmarried lady. (E. R. S. repeats 
after Mrs. G.) I don't know. Wo-g en-sin g-sha. Please 
say that again. I can remember it from the. beginning to 
the end. My humble name? This is the business life (to 

133 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Dr. G. when she comes to take the reflexes). (Asks to be 
excused for having forgotten to take off her glasses before 
the eye reflex.) I suppose I ought not to drink. 
4:30 p. m. Pulse 100. 



REFLEXES 



/. Pupils 
Light 


Size 

with electric light 

at arm's length 


Same . 
at 1 ft. Accommodation 


Crossed reflex 


R. Slight 
L. Slight 


5 
5 


5 Absent 
5 Absent 


Absent 
Absent 


//. Patellar 








R. Normal. 
L. Normal. 








///. Plantar 








R. Normal. 
L. Normal. 


Response to intense stimuli. 
Response to intense stimuli. 





While the Babinski reflex was being given, E. R. S. 
mumbled something like "needle — shi — ooch. I feel like 
April clothes. Thank you." 

(Notices conversation going on around her.) "Are 
you going to say something? I am all right. Falling off? 
(Says disinclination to talk is growing very much.) I 
could go to sleep now dead easy. When will Dr. Y. be 
here?" 

Don't know what I was going to say. Don't work too 
hard at it. When does the next hypo come ? The next will 
be the third. Very little idea. I want somebody to take 

134 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Dr. Y. and Miss T. When is supper? (asked to speak 
louder). Louder than this? My Adam's apple is all out 
of commission (asked if she sees two heads on the doctor). 
Only one head, only one visible. My hands feel very 
funny. That reminds me, Mrs. B., when I was taking your 
test on your knees — well, what was I talking about? — I 
haven't the remotest idea. My lips are so dry I can't 
smile, and that's a terrible calamity. 

(Asked if likes scopolamine and why not?) No. The 
last tasted so metallic. I don't like it. (Asked if she 
would like a drink of water?) No. This isn't hydrophobia. 
Frightfully funny. (Laughs.) (Later says she refused 
the water for fear of being nauseated.) 

Don't know what you are going to do. I would know 
that voice with my eyes shut. I'm just like the White 
Linen Nurse. My mouth is so dry. (Later in the evening 
said:) "I had struggled in vain to say, 'My noble expres- 
sion aches like the White Linen Nurse.' " (Asked if the 
light bothered.) No. My lips are so stiff. 

TEST VIII 

4:45 p. m. Third Test of Orientation. 

1. What is your name? (1.8 sec.) (Frowns, hands on 

eyes and laughs) Elisabeth Shaw. (Disgusted, 

pained expression.) I guess not. I would go to 

135 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

sleep if I had that. Can you tell by my action when 
the effect of the medicine is at its height? (Laughs.) 
I don't know what. Oh, dear, it's so funny. I feel 
all puckered up, my mouth is so dry. (Laughs 
and giggles, hands on eyes and nose.) (Later says 
that at this time she was struggling to keep from 
weeping.) 

2. When is your birthday? (2.0) Fourth of July. I 

feel as if part of my mouth didn't belong to me. 

3. How old are yon? (1.5) Thirty-nine. 

4. Where is your home? (1.4) Evanston. 

5. What year is this? (1.4) 1915. 

6. What month is this? (1.5) Jan. I don't know 

why I abbreviated that. What time is it? I want 
to keep awake until Dr. Y. comes if I can. 

7. What day of the month is today? (.8) Eighth. 

8. What day of the week is today? (5.3) Friday. I 

don't remember. 

9. How long have you been here? (3.4) Oh, maybe 

an hour and a half. 

10. In what city are you now? (.8) Chicago (opens 

eyes.) 

11. What kind of house is this? (1.2) Hospital. 

12. Who brought you here? (No response.) (Puts 

hands inside of Chinese gown which she is wear- 

136 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

ing.) Who brought you here? (1.8) I brought 
two other people? It's just the other way around. 
They are going to mail me the specifications for 
the ranch you told me. {What did you say?) 
Nothing. I have no idea what I was going to say. 
Does it seem uncanny to you all? (To Miss T.) 
That's the rules of the game. (Shakes hands and 
feels of them and laughs.) It feels so excruciat- 
ingly funny. 

13. Who are the people in this house? (2.2) Doctors 

and nurses and patients. 

14. Who am I? (1.6) Ada. 

15. Where were you a week ago? (2.0) Evanston. 

16. Where were you a month ago? (1.6) Evanston. 

17. Where were you last Christmas? (1.2) Uncle 

Albert's house, family reunion. 

18. What did you get for Christmas presents? (1.2) 

Isn't that funny? That's just what I was trying to 
tell you before you asked. Can't you be a little 
more comfortable, Mrs. G. ? Isn't there another 
chair for you? Limp as a dish rag. Lay off some 
and keep the more efficient ones. 
What did you get for Christmas presents? (7.0) 
Miss Townsend, Miss Foster. 

137 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

What did you get for Christmas presents? (7.0) 
(Shakes head.) I don't know. What number is 
that? What's the number of that question? Before 
the time for the next dose comes, hadn't I better slit 
up the back of my nightgown so you can get at my 
spine ? 

19. Are you sad? (1.7) No. (Shakes head.) 

20. Are you sick? (1.0) No. (Moves head, twitches.) 

Where is the lid of the fountain pen? Now the 
second dose is given at 4:00 o'clock; then, after 1 
scolded him. I told him I wasn't sure men were 
admitted — for women and children — cart wheel, 
I said. I know I don't know what I mean. 
(Laughs.) 

21. Why do I ask you all this? (2.0) (Laughs.) (One- 

sided smile to left.) Perfectly coherent — seems 
that way to me. Did you do anything to me? 
Miss T. ? Was it something I said? I didn't find 
myself to roll down Pike's Peak — and you know 
I know how silly. (Laughs.) 

TEST IX WEIGHTS 

4:50 p. m. 

A. T. : Which is heavier? Weights put in hands. She 
holds weights helplessly, one in each hand. 

138 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

E. R. S.: (Laughs.) Take all I can and keep all I 
get. Feels so funny. (Hands on eyes constantly and still 
fingering bed clothes and hands. Question is repeated.) 
Did I measure this the last time, too? Now you see, this 
is the most uncanny thing about it all. Have taken it away. 
Otherwise I suspect I was near the Northwestern station. 
{Repeats question.) (Oh! Oh, that would be fine. (Re- 
peats question.) Nonsense, people thought. 

Can you hold that tight? Maybe. If you will promise. 
Oh, that's so funny. (Laughs and puts hands over eyes.) 
A. T. repeats question and says, Feel them.) But then it 
was all unexpected to her. I don't think silver dollars — 
she just has given you guesses. (Seems not to know she 
has anything in her hands. Rubs eyes and nose.) 

(An electric light was changed in position. E. R. S. 
seemed to notice it and was asked what happened.) I 
don't know. Street car — your watch on your hand — must 
keep awake — yes, I do — I want to get the inside things 
about how it acts on you. Mrs. G. is going to give me 
a lot of Chinese — is that light in your eyes? Now, isn't 
that funny? 

Mrs. G. asks: Where did you live in Tungchowf At 
the East Gate. My cousins. In Wei-hien I sent back word. 
Over here on the south side somewhere. Her cousin and 
she have always been bosom friends. Opposite in tem- 

139 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

perament as can be — not going to give them as a special 
test — just give picture story — don't believe he's as brave as 
all that, is he? Who's brave? I don't know. 

Did you ever go to Wei-hien? Yes, just passed through. 
Went Kee (hesitates). What's the rest of it? (Then 
E. R. S. got it correctly.) Tsi-nan-fu. Whom were you 
with? My mother. Am I worrying you any at all? All 
right, I will try to get loose. All tied up sitting around 
here. I think so. Where was it Di-shan-sung lived? Oh, 
this is a lovely question. It's just off around the corner 
from giving people a clearer. Giving them what? Can't 
you tell me? Oh, haven't I told you yet? Where was it 
running? Was what? Di-shan-sung called observatory. 
What else? Don't think of anything else. The bed is very 
comfortable. Won't have to have the screen up. What 
did they do with the Gwan-yin? That happened so long 
after I went away. Did they really have to tear it down? 
Hum. How is that? No, I mean the image. What did 
they do with the Gwan-yin? It's an hour and a half from 
Wendell Phillips, is it? Don't you remember what they 
did with the Gwan-yin? No. If the baby is either born 
dead or is (laughs) — sorry, I didn't know Mr. G. was 
around. There's no telling what I'll do. Does it have to 
be in? Now, there was one other thing I wanted to ask 
before I go to sleep. We are going to have two of the 

140 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Giessen tests. Then slowly, so she will get the gist of the 
thing. Seems to me she has really quite a lot to learn. 

5 :00 p. m. Third hypodermic is given. Morphine *4 
gr., scopolamine 1/100 gr. 

Pulse 100. 

E. R. S. : Don't think the second has come yet. Xurse : 
How many have yon had? I think it's only two, but it 
may be the third. What does this one make? I think it 
makes the third. W here did yon have the first one? Was 
it maternity business or was it purely benevolent? She can 
observe better if she hasn't anything else on her mind. 
How many hypos have yon had? Blessed if I know. 
How many do yon think yon have had? I know I have 
had two. You are giving me one just now. Was this the 
second one? Do you want me very much for something? 
Oh, it's the nurse. I thought you were Mrs. G. all the 
time. You see, it is awfully hard to match up with the 
words that I may happen to remember. I strike out for 
something, but I am just as apt to meet something else. 
I feel so utterly silly. This is terrible. You see they are 
trying to get water on our ranches. I forgot what I was 
going to say. In Idaho that's my chief interest. It's my 
only recreation. I go to the movies only about once a year. 
That's my next chief interest. Please don't be too consci- 



141 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

entious, because I'll scold you if you are. I had a feeling, 
just then, that you are one of those waxwork figures. My 
head hurts. 

(She is handed weight in box.) E. R. S. : What is she 
to compare it with? I am a remarkable scopolamic reac- 
tion. This sounds as if she had a great deal. 

Which is heavier? I can see things floating around over 
there. You know that it is an evidence of delirium tre- 
mens. (Hears some one asking about a pen, turns over in 
bed and points toward table.) There is a pen over here. 
(Correct.) 

What is this? Weights. Evanston Public Library, 
1944. {Question repeated. Changes boxes and repeats 
question.) E. R. S. : Have you asked me that before, or 
haven't you? When I come back I am going right to 
sleep on the sleeping porch. What have you in your hand? 
Weights. I might have said pill boxes. I might have said 
fool boxes. (Something else we could not understand.) 
Where were those women? There was one in Darmstadt. 
A whole week or ten days of it — and when we got through 
we were all banged up. This was meant to be so. Which 
is heavier? That lady that does such nice writing for you. 
Preventive, Mrs. B. Which is heavier? Wasn't that 
funny? Now I lay me down to sleep. Offensive condi- 
tion, no, a friendly condition. Were you? I guess not. 

142 



SCOFOLAMINE-MORPHINE ANAESTHESIA 

Which is heavier? (E. R. S. shook hand and had it 
right. Question repeated. Shakes hand.) 

Do you know Mrs. G.f Yes, I have seen her only about 
thirty miles to interpret her papers, do you see? When 
did you see Mrs. G. last? Saw Ethel — that firm — I wasn't 
provoked at anybody. 

What color is Mrs. G.'s dress ? (Silence. Question 
repeated.) I haven't seen the clock at all, you know, this 
morning. If Dr. Van Hoosen's sister and her cousin, both 
of whom have the governing of the thing — 

TEST X 

5:18 p. m. 

E. R. S. : They've interlocked my fingers. A. T. : 
Would you like to undo them? Yes. 

Fourth Test of Orientation, etc. (Prof. Sommer.) 

1. What is your name? (2.0 sec.) Elisabeth Shaw 

(mumbles). Do we have to go now? 
\y 2 . When is your birthday? (1.4) Fourth of July. 

2. How old are you? (3.0) For that number, please, 

I am unexpected. Make it up — away. 
How old are you? (No answer.) (After about 16 
minutes opens eyes and mouth and puts hands to 
eyes and then back to folded position on chest. 
How old are you? (4.5) I am more than 75. 

143 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

3.. Where is your home? (1.4) Haven't any. 

4. What year is this? (1.0) (Murmurs indistinguish- 
able words.) (Picks tooth once.) (Scratches 
bedding with fingers.) Catholic O, ordinary Amer- 
ican. 
What year is this? A dog — for the benefit of — and 
now that I put — 



5:25 p. m. 








/. Pupils 


REFLEXES 

Size 

with electric light 

at arm's length 

sy 2 






Light 

R. Absent 
L. Absent 


Same 
at 1 ft. 

5/2 

sy 2 


Accommodation 

Absent 
Absent 



//. Patellar 

R. Normal reflexes. 
L. Normal reflexes. 

///. Plantar 

R. Sluggish — slight Babinski on first Stim. Later normal response. 
L. Marked Babinski on first stimulation. Normal response to repeated 
stimuli. 

(Tries to pull dress down when doctor tries the knee 
jerk. Still gets reflex on both of them. Babinski decided 
on left and slight on right. 

E. R. S. : I understand more, for instance, this medical 
German. Five very nice you have splendid — water lilies — 
I may not be able to do it immediately, but if not, sound 



144 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

the stub. Published in a magazine and was never exam- 
ined before (very thick). 

A doctor asked: Are you having a good sleep , Miss 
Shaw? Yes, very. 

Doctor: When are you going to have your operation? 
(Smiled.) Because little pitchers have big ears. You know 
she goes by the elevated, gets off at Marshfield station, 
and then there is that overground. 

Do you know Chinese? Yes, that's just the beauty of 
it. I don't quite remember that quotation. (She is asked 
to say it.) One can do it in three minutes nearly every 
time. 

(After this the sleep became so deep that all efforts to 
rouse her failed except an occasional question, and stimula- 
tion of her rote memory of Chinese. Her name was called 
again and again, but she made no response.) 

Mrs. G. : Let's say it again — wo-men-tsai (beginning of 
Lord's Prayer). (Repeats these three words twice. Tries 
yin yin.) Have just come upstairs — no, half an hour or so 
ago — ambulance — the ambulance for carrying the thing! 
Let's try wo-men-tsai (Lord's Prayer). Sure I do. Say it 
with me, then. (Mumbles something unintelligible.) Un- 
yan-gen-shai — I haven't — literally. Yin-yin-shin; finished 
the line correctly. Whan-hi-tien-tang; E. R. S. blows out 
of corner of mouth. Repeats four words, pa-di-yu. Not 

145 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

going to miss economy. Oh, Mrs. G., I wonder if I had 
better take the voices. (Rubs lips.) I didn't expect to 
have to see her. Yin-yin-shin-li-yow-ku-fu (repeated with 
E. R. S.) (Neck flexed by nurse, but made no difference; 
tried again.) Van Hoosen — if she could possibly strain 
a point — I wish you would ask her if she could. 

That last sentence was the one I was waiting for. I am 
going to Europe for Giessen tests; how silly she is; if they 
were poor people they would have been requested to leave 
- — perfectly reliable- — you can trust. Trust what? If you 
could remember. Something very valuable — you know that 
type, don't you? Tantalizing and smiles — I believe Dr.; 
some time. 

Would you like to go to sleep? (Blows hard through 
her mouth.) I am in very great comfort — so utterly non- 
sense she went to — (mumbles). 

(Some one calls her name and asks her if she is having 
a good time.) E. R. S. : I am all straight except when 
I talk Chinese; so much worse when they — scattering 
attention. Do you remember Chinese? Can you say the 
Lord's Prayer in Chinese? Miss Shaw, can you say the 
Lord's Prayer in Chinese? Could you say the Lord's 
Prayer in English? Yes, of course I could. Let's hear 
you, then. I don't suppose — would be a profession with 
him — you can't measure the degree of testimony by — 
protest. U6 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Where are you, Miss Shaw? I am at the bank. What 
are you doing at the bank? I am just taking out a charge 
account. What are they laughing about? 

TEST XI 
5:50 p. m. Fifth Test of Orientation. 

E. R. S. : Perfectly fascinating — besides, I am examin- 
ing. 

(During this test, Dr. S., sitting at head of bed, repeated 
each question, as A. T.'s voice did not seem to rouse 
examinee, not even when words were spoken directly into 
her ear. Voice of E. R. S. very indistinct — exceedingly 
difficult to understand. She picked at something most of 
the time; rubbed nose and eyes; occasionally opened eyes.) 

1. What is your name? (No response.) 
What is your name? (1.5) Elisabeth Shaw. 

2. When is your birthday? (No response.) 

When is your birthday? More than she could. (The 
doctor flexed her neck and repeated the question.) 
(No response.) (E. R. S. looks around at people 
on both sides of the bed. No response.) 

When is your birthday? (2.5) Jan. 27. (Note: 
This is the date of the coming Congress on Anaes- 
thesia ! ) 

3. How old are you? (Moves mouth.) (No response. 

Mumbles and picks at hands.) 

147 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Miss Shaw, how old are you? (Doctor flexed her 
neck.) (No response.) (Notices that her hair 
is disordered and tries to arrange it.) 

How old are you? (Doctor speaks louder than be- 
fore.) Lively old soul. For those few days at 
Mrs. K.'s she simply couldn't wait. 

How old are you? Well, it's this way. (Pats A. T. 
gently with hand.) 

4. (Omitted.) 

5. What year is this? If you are going to be in the 

city — mothers. 
What year is this? 1915. I said it because it was 
impossible that so — religious instinct. 

6. What month is this? (Repeated four times, using 

her name.) Had a beautiful lesson (repeated) 
(deep breathing). 

7. (Omitted.) 

8. What day of the week is today? (Tries to answer, 

moves lips, but makes no sound.) 
(6:00 p. m.) 

9. How long have you been here? (Moves lips.) Ever 

since last September. 
10. In what city are you now? (Smiles.) I used to be 
troubled awfully with insomnia. 
In what city are you now? Chicago. 

148 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

11. Who brought you here? In this particular case — a 

great exception, of course, but I want it to be a 
success. 

12. In what kind of house are you? (Smiles slightly and 

tries to sit up.) 

13. Who are the people in this house? (Smiles.) It 

really is worth it for that price. Nurse: What 
do you see, Miss Shaw? (No response.) Which 
book is this? {Who are the people in this house?) 
(Nods and smiles continuously, as if to say, 
''Everything is all right") 

14. Who am I? (Smiles.) That's pretty hard — came 

over this afternoon — Mary Thompson Hospital — 
Miss Townsend's house. (A. T. repeats question.) 
Follow somebody else's — for this reason. (Pats 
A. T.) Don't know antecedents, but they are go- 
ing to operate, probably. (Smiles.) 
(Questions 15 to 17, inclusive, omitted.) 

18. Are you sad? No. 

19. Are you sick? (Smiles.) Yes. I am so sleepy — 

keeping awake — let me see now — one night — just 

simply — I know (smiles.) 

E. R. S. : They don't stop to give their own concept — 

telephone number 25 — Freiburg — paper — I just brought — 

computation — to find out — I don't know. Why are you 

149 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

sleepy, Miss Shaw? Are you sleepy? Like sixty, yes. 
Why? Because it — {Question repeated.) (Tries to 
scratch.) You should have faith that I wouldn't do that — ■ 
I am mortally afraid, not of the thing itself, but that the 
public would misunderstand it — co-operate. 

(A. T. calls "Bessie.") Yes. Who spoke to you? (No 
response.) (A. T. lies down beside her, in order to hear 
more easily her almost unintelligible mumblings.) 

A. T. : Elisabeth? E. R. S. : So, after the rebellion, 
twenty-five years ago, she doesn't like it. Elisabeth? 
What do you put on there, time? I could help you carry 
things — Heller effect. Do you know Mrs. G.? She has 
been with me this afternoon. You know she is teaching 
three times a week — and if they should want her on 
Christmas this week — yes, I do — around the world very 
slowly — certainly if they are the very least observing — 
also about Dr. S. W. — have I told you about her — how 
did you come by 38? I want to relieve the anaemia in my 
head — at the same identical moment (snuggles up to A. T. 
exactly as if she were awake) simply do the most unex- 
pected things you could think of — not quite that — you will 
have a little time — I am relying on your word memory — 
and mine — did you tell which floor it was on? You see, 
I slept there last night, so I know the situation better than 
people who have lived with those people for a thousand 

150 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

years (told her to put her arms around A. T.'s neck, and 
she did it, and gave her quite a little squeeze). Lovely — 
I'd like to have her see how we publish this. 

What color is that, over there? (White.) (No re- 
sponse.) Do you know Dr. S. W .? Have it there all safe 
and sound all the time. Astounding — room there — previ- 
ous association — leave the package here at the door. Do 
you know Dr. S. W .? Sure. I know several languages — 
College. Elisabeth, will you move over just a little bit? 
Sure. (Moved readily.) Do you know who this is? 
(E. R. S. fusses with fingers.) Who am I? Do you mean 
you are taking these matters into your own hands for con- 
siderably more than half a dozen, in all probability? 
(Confidential tone.) Did you get it? You are awfully, 
awfully good to postpone — 

Elisabeth, do you want to rub me a little? I would love 
it — I was waiting and watching for the opportune moment 
— now if anybody would come in I was enormously inter- 
ested. Are you sleepy? Just a moment (mumbles). I 
can't thank you — I can't do it satisfactorily without — 
Does your hair bother you? (Shook head.) No. 
(Moves, tries to sit up in bed.) I can't imagine why a 
few days at home should make her impudent — now don't 
you get that all mixed up — if drunk, support (puts out 
hand to Dr. Y.). Now isn't that cunning? I needed it 

151 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

down in the city this morning, but hated to carry it back 
and forth — however, it will come out all right. 

Are you cold? E. R. S. : White — ring around the 
mouth — she did (laughs). I don't seem to have sense 
enough to father my book, but I have not got it written 
yet — it's only within the last few months that I have had 
any pleasure out of my acquaintance with them — so I am 
being at the hospital just as much as I can — joint meeting 
of the Medical Congress — you know I talked Chinese for 
the first nine years of my life (turns over on side). I am 
scared to death — you know this is Chicago, and Chicago is 
dirt — and you know keeping it within — those little papers 
of Mrs. Odell's — (reaches over and taps A. T. on the 
arm; makes little noises) honorable food — dear, I am 
scared for fear I'll sauce my hands up — just a moment, 
Doctor, and then I'll let you know immediately after that. 
6:35 p. m. 

E. R. S. : It takes number 12 (smiles). That's right 
(feels of ears). He'll make no objections if I discover 
things all up and then he'll wake him when the train 
arrives — meanwhile you will think of what is going to 
happen at the county tomorrow — now it is just this mat- 
ter — a perfectly open-minded person — I know, but you 
permitted me once to stop you, so roll it up — the worst 
half of Chicago, no matter what tests or what experi- 

152 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

merits — Dr. Y. — Dr. Y. — What will I do, what can I do, 
to get the wrinkles out of there (says this with hands on 
A. T.'s face) and get you rested up. (A. T. said: That 

means me.) E. R. S. : I know it p . She may 

have an abundance of nice clothes — the middle of the long 
horizontal is right there — talk about problem in arithmetic — 
personal — sort of friendly affair. 

A. T. : Elisabeth, what is Caroline's other name? 
E. R. S. : (answers correctly). Nurse: Did you get the 
blotter? Yes. Who brought it? I believe it was started 
with President C. S. — the last time I went home from the 
hospital — Are you warm enough? Oh, yes — being denied 
the pleasure of seeing me go under these tests and now 
after only a very few tests I believe Orientation and 
another book tells it all. (Accidentally bumps A. T.) 
What will I do next? (disgusted tone). Demmit, demmit, 
demmit — I have to catch a train — it is supposed to go at 
1 :22 and I think it practically always does. 

(Dr. Y. rings bell.) Just a little after 7:00. (Sits up 
in bed and hunts for watch under pillow.) Yes, I know 
all about it — sapphire — I had it polished and set in a ring 
for goitre reduction — it was lovely reduction — I am crazy 
to have another talk with you and I am looking forward 
to it with very zestful — 
About 7 :00 p. m. 

153 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

(We went downstairs to supper, leaving E. R. S. in 
charge of a nurse. As soon as we came into the room, 
when we came back, she stretched out her arms to us, and 
was sitting up, looking bright and wide awake, smiling.) 
E. R. S. : I know that every night I have been coming to 
the hospital except one have been battles for this little 
white child — it has got to be convincing or not at all. 
About 7 :30 p. m. 

(Dr. V. H. asks her what the blanket is.) Blanket. 
Are you warm enough? Yes, thank you. Are you? Not 
too warm? That's funny, when you are not left-handed — 
that isn't deft (or delft) blue, is it? Now you know the 
points better than anyone else in the city. 

What is this? A blanket, but it's so thin, might as well 
be killed for a sheep as a lamb. Do you want to lie down? 
I wish we had twin beds — as soon as the parents began to 
realize that I was a simple enough individual, it began to 
be interesting. 

(E. R. S. recognized Mrs. B. and then said to A. T.:) 
Not sure that business is best for her (some lost here). 
Just what I wanted. I want a typist — I want all rubber 
and hardware handled — always have my watch here — the 
doctor that's going to give me this twilight sleep has done 
it in 5,278 — Chicago attempts at pronunciation of foreign 
names — she is just on the crest of the Ravenswood just 

154 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

now — I am not testing for the quantity of memory regis- 
tered — just three or four Orientation — reach me your — we 
want a substitute for the Fall River Bank. Who do you 
think you will get? I am exceedingly interested. (Flash- 
light explodes.) (Asks Dr. Y. if light isn't too strong on 
her.) What makes you think that the light is too strong? 
Because your mouth twitches, has a headache in the back 
of her head, but I think there will be no complications — 
I just sort of feel as if I belonged — I remember a large 
part of it. But there is apt to be sleep — I don't think they 
will have that particular kind of army. 

(Just here E. R. S. decided she ought to go home.) Got 
them at a time when Florence was in a very bad condition. 
That's what Mrs. Reuf said she wanted for a memorial to 
her son — these things that bolster up your enthusiasm and 
on the other hand keep you from (looked in somebody's 
mouth) — Q. : What do you see? I saw your mouth 
and very little else — that is very characteristic and what 
you would expect from a lifelong ruler. 

What is that? A Marshall Field advertisement, Fash- 
ions of the Hour. (Measured A. T.'s width of head and 
length of nose.) In a large percentage of the cases I have 
been watching are drinking too much — very familiar physi- 
cian — another doctor from the west side, her name is 
Harrison — you know her. 

155 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

(Dr. Y. gives her quinine.) What is it? Do you like 
it? I am too tired to like it yet. Did Dr. Y. give you 
anything in your mouth? No, not yet. She told me to 
shorten my working hours in the actual examining — I don't 
like people spoiling — I don't see any reason why there 
should be nassness of the skin — I wanted to see Dr. Y. 
because she knows me so well and she is one of the most 
famous operations in the world. 

Dr. V. H. explains how we came by the name "scopola- 
mine." At the end E. R. S. said: Well, then, where shall 
I meet you ? — a splendid one for inference then. 

(Dr. Y. sticks her finger with a pin until the blood comes. 
E. R. S. is looking at her. Dr. Y. explains that she wants 
to make a little blood test.) Does it hurt? E. R. S. : Not 
much — all right now. Do you want a drink? I think 
I had better not take a lot, but I would like to have it 
around. Why? The scopolamine might deteriorate. It 
does often. Is that basket all full of things to sprinkle on 
me? What did you throw away? Congratulations, mixed 
in very strongly with my confidence. My dear, the baker's 
boy himself wouldn't have stolen a bun — how perfectly 
silly. 

A. T. : Don't you want to tell me something about your 
sub-conscious self? E. R. S. : Not before all these people — 
if you people are here I will just go about the business of 

156 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

life at the other extreme — good night — Hyen-tsai-woa-yow 
(Now I lay me) — it isn't 12:00 yet (looks at her watch). 
She is going to get on at Dempster Street — a thousand 
thanks — and Caroline really is consenting to the fact 
that — to go on a bust and get all cut up — if you are not 
going away too soon — did Caroline give you back the old 
talks — deliberately taught to her — this stream of phan- 
tasies — lack of inhibition if writing premises — it is some- 
times embarrassing when they get balled up in their corre- 
spondence and duties. 

Don't you feel a little bit tired? Terribly; dreadfully 
tired for the last three weeks — I can't get used to — at Mrs. 
Tufts' house, 620 University — where is Miss Townsend? 
Away for the afternoon for some missionary meeting — 
school pupil, between 90 and 99 in all her studies, but her 
schoolmates simply could not stand for it — I must go. 
Tomorrow morning I am going up to Evanston. 
About 7 :40 p. m. 

(E. R. S. was given raw quinine on tongue.) E. R. S.: 
Feeding the birds — now if I might have that glass of 
water, please, I want to get this bad taste, metallic. What 
is it? Scopolamine, and she gives it in bigger doses, oh, a 
combination of sweet and bitter — very dry, not exactly 
thirsty. There is a difference between being thirsty with 
every muscle and nerve crying out — extraordinary size of 

157 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

hats — I am going to miss my train if I don't go. May 
miss my train now. (We told her the train had gone.) 
I don't care a hang for your hold. (Told her there were 
no more trains tonight.) Is that so. Well, how astound- 
ing. 

TEST XII 
7 :45 p. m. Sixth Test of Orientation. 

What is your name? The same words, don't you see, 
that I gave you for this preliminary test. (Turning to 
Mrs. B.) You don't need to write that, of course. I am 
absolutely sizzling with curiosity as to what is going to 
happen. The consensus of opinion seems to be that it is 
perfectly safe. Did you get the newspapers? Well, then, 
let us go. (Told that train has gone.) Oh, you belong 
to the Ananias Club. 

1. What is your name? (.8 sec.) Elisabeth. 

2. When is your birthday? (.8) Fourth of July. 

3. How old are you? (1.8) She says when people 

go away. 

3. How old are you? (2.0) Thirty-nine. 

4. Where is your home? (1.6) Chicago. 

5. What year is this? (2.0) (Points to ceiling.) I 

certainly have a jag on. It's a teeny little thing 
running around in water — loveliest thing you ever 

158 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

saw — the way she learned — Cascarets — do you 
know what I mean? I am not at all sure. Mrs. 
B. will think we are entirely uncivilized. (Note: 
This word Cascarets was intended as a joke, to 
express the fact that A. T. was working while 
E. R. S. had the twilight sleep.) 
6. What year is this? (1.5) I want to catch that 
train. What's the State Land Commission for if 
they can't wake us up in the morning! It 
wouldn't take much time or strength to run. 

6. What year is this? (1.0) 1914— No, 15. (Asks 

Dr. G. to sit over closer.) Sit tighter, please. 

7. What month is this? (2.0) January. 

8. What day of the month is today? (2.4) Eighth. 

I am worrying, incidentally, all through this for 
fear they won't have the proper kind of dinner — 
guests — would like to be a saleslady; would like 
to perform, oh, all sorts of things — dead sure we 
have missed that train. Now, if I weren't a Pres- 
byterian you would hear something from me just 
now ! — if there is any sleep in me, I will — these 
little squares and things and label them all and 
you will be world famous and that's all there is 
to it. 



159 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

8. What day of the month is today? (1.3) I told you 

that once. I am awfully sorry this came on a Fri- 
day. (Why?) Well, perhaps I am prejudiced, 
but one street down here that I have to take 
oftenest has no intermission. I have not answered 
your question and I know I don't know what the 
question is. 

9. What day of the week is today? (1.8) Friday. I 

have told you three times. I am past-master at 
the art of making faces. Why can't I get to that 
hospital — just telephoned. Why didn't you tell 
me so? 

10. How long have yon been here? (2.2) In this 

house? An hour and a half. May be — may be 
much less — sum total of righteousness inside. 

11. In what city are you now? (.8) Chicago. I am 

enormously wide awake — I have been before 
for 

12. What kind of house is this? One-sided frame. Say, 

honey, may be I have got delirium tremens. Look 
at that chap swimming. I'd like to be able to 
swim like that! Oh, see those jerky jumps! 
A. T. : What is swimming? Why, it's a tad- 
pole, the prettiest little thing, swimming down a 
beautiful ravine. I am distressed at not being at 

160 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

this moment at the Northwestern station. You 
see, she wrote me about it three weeks ago. (Who 
did?) Dr. W. is for children's diseases. 

13. Who brought you here? (2.4) Brought myself. 

14. Who are the people in this house? (2.0) Tell me 

the dream and I will interpret it for you. I am 
hanging on to the previous question, so put a 

blue 

14. Who are the people in this house? (1.8) Hedging 
again. Now isn't that funny! 

14. Who are the people in this house? (2.2) Nice 

people. Truly, I have got that girl on my mind. 
She is about to be married and just got me a new 
address book. I am going to weed out some of 
these. I have absolutely no distinction as to 
which nation is friendly or unfriendly to us. If 
I had intuitions I wouldn't use them because it 
is so unscientific. 

15. Who am I? (4.7) A lassie. (Smiles and reaches 

out hand to examiner.) 

16. Where were you a week ago? (2.4) In the 

loop. I don't know just how he manages it. He 
has a pretty office in the loop. I guess I meant 
Rosie or something like that when I said "look." 
I promised that young girl I would be there, at 

161 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

the Northwestern station. ( Telephoned her, we 
said.) That's dear of you. I am getting crosser 
every minute about the writing. Will have to do 
as the three sleepers of Bonn did — morphine 
makes it itchy. 

17. Where were you a month ago? (1-4) Evanston. 

18. Where were you last Christmas? (1.0) Uncle 

Albert's. 

19. What did you get for Christmas presents a year 

ago? (1.4) I have already told you three 
times. The girl ought to have more physical ex- 
ercise, swimming or some good stiff physical exer- 
cise, etc. Business men like to do that sort of 
thing and progressively bind a girl to them. Just 
when did you telephone Mrs. K.? 

19. What did you get for Christmas presents a year 
ago? (7.2) (Laughs.) (Whining tone.) What 
is the matter? It's that blamed big spider. And 
I have delirium tremens. Were you absolutely 
sincere? Is it a boy or a girl? 

19. What did you get for Christmas presents a year 
ago? (9.5) (Hands on eyes.) I can tell you 
lots of things I am going to do. Going to build 
more dotted Rufus maps, dotted all over the 
country. C. is going to be a peculiar proposition. 

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SCOPOLAMINE-MORPHINE ANAESTHESIA 

19. What did you get for Christmas presents a year 

ago? (3.4) Comb and brush, paste map or map 
paste, I don't know which. Now, either you 
have put that up to fool me, or it is moving. 
(Laughs heartily.) I don't believe I had another 
birthday this year. May be I am not born yet. 
Now, I am lost — no idea what I was going 
to say. 

20. Are you sad? (1.0) No. 

21. Are you sick? (.8) No. 

22. Why do I ask you all this? (3.6) (Sighs.) Per- 

haps to begin practicing all the labor-saving de- 
vices you can get hold of. That isn't well done. 

(Finished this test at 8:10 p. m.) 

(Dr. Y. gives E. R. S. ammonia to smell.) E. R. S. : 
Ammonia. (Held to nose again. Are you sure?) Well, 
it's diluted, I couldn't stand it that way if it weren't, could 
I? (Rises of her own accord, combs hair over by dresser 
where it is dark and finds pins and combs without help. 
Talks about cerebellum, while doing hair, and process of 
elimination.) 

E. R. S. : And when she gets on a blue dress, her eyes 
are like a scrap of the skies. And the scopolamine in- 
creases her color. (Remembers combing her hair.) I 
thought there was some sort of distaste in my mind. You 

163 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

know I was brought up to believe that dancing, card 
playing, etc., are wicked. My mother would have been 
exceedingly distressed — I sent you a book, didn't I — Mrs. 
Newman — Mrs. Ferguson — does urn's head ache — there 
is always a cause for that — there usually is a dollar bill 
floating around over there, in the suitcase, in the lid of the 
suitcase. 

8:25 p. m. 

How long do you think you have been here? (1:22) 
Must be just about 4:00, and that spider is crawling. (Q. 
repeated.) Just off and on. You can't measure it any more 
than a Methodist minister. (Keeps constantly asking Mrs. 
B. if she is going too fast for her.) Eleanor L. — crawling 
again. {Are you afraid?) Not a particle. Would rather 
have the deceits in the open. I did not quite understand 
the question. (Q. repeated.) A whole lot of words — I'm 
simply dying to comb my hair and I can't get it out of my 
system that it's done. 

8:30 p. m. (Told Mrs. B. a story about a college 
boy, who said that every morning he sprinted around the 
athletic field closely followed by a shower bath. Forgot 
the story in the middle, but the word "dean" resumed it.) 
Professor Burger told me, but I don't know whether he 
saw it himself or — what was I talking about anyhow? 

(Asks about Mrs. G., what became of her, why did 

164 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

she go?) She didn't do a thing for me. Do you re- 
member? Wrong — school teacher — now I am getting all 
mixed up with land water in the first act — hat bonnet — 
not tone voice, but maybe it was voice (gone again) very 
particularly beautifully furnished chapel. (To Mrs. B.) 
I don't know as I would put that down, as opinions might 
differ. That's really esthetic. Oh, dear, I wanted to see 
Mrs. G. Memory for past events and memory for recent 
events. You don't have trouble with either, do you? 

How are you feeling? Fine. He was here about an 
hour ago. Don't notice them at all. Are you talking 
about Rufus or some name like that? I don't know what 
I am talking about. I sort of want to laugh and cry at 
the same time. (Mumbles — pictures.) I dislike Corot. 
I love Inness, and the more modern pictures are more 
likely to taste stale. Before an Inness I could gaze myself 
away to everlasting bliss. Couldn't I tell you, to save 
time — indicate what you were talking about. What was 
the question? 

I have no consciousness of having been out of this 
room — suggestive question — I won't fall to it. 

(Tells story about a woman who got up and walked 
down the hall and when asked what she was doing, said, 
"Taking a little exercise." Obstetric case.) Am planning 
to sleep most of the time from now until Monday morning 

165 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

so as to have full internal evidence. I have been so tired 
all fall and am looking forward with great pleasure to 
a couple of days off with enough medicine to keep me 
from worrying. 

(Says something that shows she remembered walking 
in middle of street as we left Evanston coming to the 
hospital — transfers prick idea to the ear — recalls teacher 
pupil; tone voice; hat bonnet. Was tying muffler and 
asks A. T. if she will have it dried. Tells about its being 
stolen in Mary Thompson Hospital. Remembers basket 
and telephone used previously in test in wrong place. 

Dr. Lilian J. — Oxford College — I attended — before 
there was instruction at the place across the river — Pough- 
keepsie — that's where I lost the thread before — (recalled 
by mentioning the doctor's name.) This hasn't had the 
third dose yet. (Says she knows it was in arms by muscle 
memory.) 

(Remembers Dr. Y.'s Christmas card. Says that she 
has no distinct memory about sending card to Dr. Y., but 
is very careful to lock the front door.) 

I don't know what we are talking about. Is it a piece 
of matting on the main mast? Tall sails — Egyptian boats 
on the Nile — not interested — name beginning with K. or 
something like that. (Later explains that she was trying 
to remember the name of those little boats on the Nile 

166 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

called Dahabiyeh. (Tries to tell a story about a con- 
ductor, says) Voice of the people, even Dr. Evans. 
(Gone again.) Mary Thompson is mentioned and she 
begging over again. (Gone in a moment.) Isn't it mad- 
dening to start a sentence and break right down in the 
middle? 

(Says) Metallic and horrid — (remembers bitter dose.) 

9:00 p. m. 

(Buttonholes Mrs. Brown when she sees her about to 
start for home — thanks her, and by seeming to try to 
think very hard remembers the things she wanted to tell 
her — that she is worried about the typewriting — that she 
wants help to learn how to write; fear that she might die 
before she gets her work on paper and can teach it to 
some other people. Unanswered letters accumulating wor- 
ries her. Then talks to me about the spider. Explained 
that it is a gas-jet and she says: "Yes, I know it is." 
Asked her if she had ever been afraid of spiders. E. R. S. 
told story about dream when she was a little girl, beetles 
climbing up her stocking and sticking her — thinks she may 
have been afraid of spiders and tells about fight between 
toad and snake on wall of Buddhist monastery — they fell 
off the wall and dropped on her. Then asks why the 
light has just been turned on. Explained that the light 
had been changed. E. R. S. says that she sees an orange 

167 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

halo about Mrs. B.'s head, and then she reasons a bit with 
herself and decides that it is simply a matter of attention.) 

9:15 p. m. End of stenographic report. 

After this time the effects of the drug began to wear 
away rapidly. The talk grew steadily more coherent, more 
connected. Examinee insisted upon combing her hair again 
and was able to do so with very little assistance, laughing 
heartily at her difficulty in standing and controlling her 
bodily movements. She had entirely forgotten that her 
hair had been combed within the hour. She recognized 
every one who came into the room, calling them by name 
and laughing gleefully over her experience. By 10:30 
o'clock she appeared perfectly natural, excepting for the 
dilated pupils and a marked tendency to forget the thread 
of discourse in the middle of a sentence. Again and again 
she would start to make some disclosure concerning her 
experience, stopping suddenly with a bewildered air and 
asking: "What was I going to say." Patient repeating of 
the previous conversation would usually remind her of the 
interrupted idea, and she would complete the intended 
sentence, remembering perfectly after the connection had 
been made what she had intended to say. About 1 1 :30 
o'clock Dr. Van H. and Dr. S. came into the room, and 
the three held a long and animated conversation, making 
arrangements for a report upon the experience. E. R. S. 

168 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

remembered most of the details of these plans, but forgot 
a few of them. By 1 1 :00 o'clock she was able to stand 
and walk about, seeming to have full control of the muscles 
and of all her faculties, excepting for the inability to re- 
member the beginning of an idea. 
Remote Ranschburg the next morning. 

TEST XIII (REMOTE MEMORY OF TEST II ) 

About 7 a. m., January 9th. 

E. R. S. I think I can remember the fifteen pairs of 
words. (Says them all except paste — canal, which she 
remembered as paste — map. Gets them all in correct 
order.) 

TEST XIV (REMOTE MEMORY OF TEST VI ) 

11:50 a. m., January 9th. 

E. R. S. Now I can remember how the story looked 
on the page, but only as individual words. I can't re- 
member any sense, although I realized at the time that the 
words made sense. In fact, I grasped the sense of one 
phrase at a time, but could not remember the meaning of 
any one phrase long enough to finish the sentence. My 
principal mental content so far as I now remember was 
a conscientious feeling that I must let you know that I 

169 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

had read part of it twice. I really cannot remember any- 
thing else about the story. 

(Stimulus word given "Italian.") 

Oh, the Italian boy was named Anderson or some 
perfectly un-Italian name. That's all I know. That's the 
thing you commented on. Yes, I remember now my utter 
disgust at the incongruity of the name with the nationality. 
Was it Anderson ? No. Did it begin with A? No. Was 
it Jones? No. Then I don't know at all. I know where 
I got the Jones, though, from the James in the other 
story ! 

(Second stimulus "silverware.") 

Why, a negro hid the silverware under his back steps. 
(A. T. smiles.) No, a negro found the silverware hidden 
under the back steps. I don't remember what the Italian 
had to do with it. (After some conversation the stimulus 
word "messenger" is given.) 

Oh, I remember; the package was marked messenger. 

TEST XV (MEMORY OF TEST III) 

8:27 p. m., January 11, 1915. 

(Retells all the points of the story correctly. Answers 
to cross-questioning as follows) : 

1. What is the story about? (2.7) Willie and James. 

2. Who quarreled? (2.6) Willie and James. 

170 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

3. Who came to settle the quarrel? (1.1) The mother. 

4. How many children were there? (.8) Two. 

5. What was the elder's name? (.7) James. 

6. How old was he? (.9) Doesn't tell. 

7. What was the younger' s name? (.9) Willie. 

8. How old was he? (1.1) I don't know. 

9. What was the quarrel about? (1.0) Apple eaten 

by James. 

10. How many apples were there? (.7) Two. 

11. Were the apples eaten? (.5) Yes. 

12. Who ate the first apple? (.5) James. 

13. Who ate the second apple? (.8) James. 

14. Did somebody cry? (.5) Willie did. 

15. Why did he cry? (.5) 'Cause both apples were 

eaten. 

16. How much candy was there? (.4) None. 

17. Who ate the candy? (1.6) Nobody. 

18. What did the mother do? (.5) The story doesn't 

say. 



171 



SCOPOLAMINE-MORPHINE ANAESTHESIA 



REACTION TIMES 



Case X. 
Orientation 


Lowest 


Highest 


Most frequent 


Av. bona 
fide ques. 


Av. sug. 
ques. 


Test I i 
\\4 hours 
before dosage 


.4 sec. 


6.6 sec. 


1.4 to 1.6 sec. (6) 


2.19 sec. 




Test V i 
immediately 
after 2nd dose 


.7 sec. 


6.8 sec. 


.8 to 1.0 sec. (6) 


1.85 sec. 




Test VIII i 
45 minutes 
after 2nd dose 


.8 sec. (2) 


5.0 sec. 


1.4 to 1.6 sec. (7) 


1.77 sec. 




Test XII , 
2 hrs. 45 min. 
after 3rd dose 


.8 sec. (5) 


4.7 sec. 


.8 to 1.0 sec. (8) 


1.89 sec. 




Story 

Test III 1 
42 minutes 
after 1st dose J 


.4 sec. 


3.0 sec. 


1.0 to 1.2 sec. (6) 


1.33 sec. 


2.10 sec. 


Test XV i 
3 days 
after dosage 


.4 sec. 


2.7 sec. 


.5 to .7 sec. (7) 


1.06 sec. 


.83 sec. 


Case A. 
Orientation 












Test I 
2 weeks 
before dosage 

Test III i 
15 minutes 
after 4th dose 


1.2 sec. 
1.1 sec. (3) 


6.0 sec. 
25.1 sec. 


1.7 to 1.9 sec. (6) 
1.1 to 1.2 sec. (5) 


2.31 sec. 

3.27 sec. 
Average without 
slowest reaction 

2.12 sec. 




Case F. 
Orientation 












Test I 
15 days 
before dosage 


1.3 sec. 


7.4 sec. 


1.3 to 1.5 sec. (5) 


2.78 sec. 




Test IV i 
15 minutes 
after 5th dose 


1.0 sec. 


7.9 sec. 


1.8 to 2.0 sec. (5) 


2.51 sec. 





172 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Introspections on Case X 

Friday, January 8, 1915. 

3 p. m. First hypo. The prick caused no pain, perhaps 
because my mind was preoccupied at the moment. Was 
surprised at absence of pain. 

Note: This being true, a pin prick in ball of finger was 
probably not an adequate stimulus to test pain reaction in 
this individual, as her nervous system was evidently not 
easily irritated by such a slight stimulus. Has had lifelong 
training in disregarding slight irritations. 

3:15 to 3:20 (time guessed). My hands begin to feel 
heavy and lips to feel stiff. I am astonished at feeling 
effects so soon. The difficulty of speech rouses my sense 
of humor. I laugh uncontrollably, have to give conscious 
attention and effort to the formulation of each word. Am 
conscious that without such effort my words would not 
express my ideas, and the absurdity of this intensifies my 
laughter. I am surprised to be so clearly aware of the 
beginning of aphasia while still able wholly to suppress its 
external symptoms. 

Note: Speech is still perfectly distinct. This is during 
the test II, and the taking of reflexes. 

After this I gradually lose the ability to estimate time. 
Am uncomfortably conscious of a few elemental emotions: 

First, embarrassment because my teeth have not been 

173 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

brushed since luncheon, hence I cover my mouth while 
laughing. 

Second, discomfort because my hair had not been washed 
recently. 

Third, suddenly I feel a wave of intense grief rise up 
from the subconscious which almost causes me to break out 
in convulsive weeping. I realize calmly that this is a 
residuum of unexpressed emotion remaining from the time 
of my mother's death, when I refused to wear mourning or 
to let myself grieve. I cover my face quickly with both 
hands and succeed in suppressing the impulse after a hard 
fight lasting until after the second dose. The motive for 
suppressing this emotion was a clear realization that this 
is one of the individual variations which the present experi- 
ment was especially designed to eliminate. During this 
time I laughed a great deal. None of the observers for 
a moment suspected the presence of the emotion. 

Note: These emotional reactions are purely individual, 
largely dependent on past experience. In this case the first 
two emotions were rather foreign to the individual's natu- 
ral temperament, but were induced on this day by some- 
thing which occurred that morning — a laughable incident 
connected with a person who was also present at the 
hospital during this experiment. 

/ remember practically all of the story told to me (Test 

174 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

III) and quite all of the list of thirty words (Test II) 
given me to memorize, hut the typewritten story which was 
given into my hands for me to read (Test VI) was almost 
impossible for me to comprehend, even while I was still 
looking at it. I glanced hack and read part of it a second 
time, then realized that this was probably contrary to the 
rules of the experiment, so I promptly confessed what I 
had done. My immediate memory of this story was very 
hazy and I forgot it — forgot that I had ever seen it — 
immediately afterward, and when afterward reminded of 
it I only remembered the general appearance of the sheet 
of yellow paper — the general location of the typewriting 
on the page. 

Note: If these tests had been given nearly at the same 
time they would give valuable evidence as to the onset of 
alexia and auditory aphasia. This subject happens to be 
strongly eye-minded, hence the great contrast between the 
retention of auditory material and amnesia for visual mate- 
rial is surprising. The enlargment of pupils had begun, 
but not enough to interfere with the mechanical act of 
reading separate words. The difficulty was doubtless 
caused by a benumbing or dissociation of the visual associa- 
tion area concerned in comprehending the meaning of 
words seen — that is, true alexia. 

After a very hazy interval I remember the entrance of 

175 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

Mrs. G. and Mrs. H., have a vivid memory of both their 
faces, and of my introduction to Mrs. H., whom I had 
not met before; remembered her name without any diffi- 
culty. I think my effort to keep from weeping ceased at 
this interruption, and I felt great relief and became keenly 
interested in the progress of the experiment. I had given 
myself previously a strong autosuggestion that I would talk 
Chinese when Mrs. G. came, but I realized that Miss 
Townsend had been on the verge of giving me an orienta- 
tion test, so I asked Mrs. G. to wait until after that. After- 
wards I succeeded in telling Mrs. G. most of the Chinese 
poems, songs, etc., which I remember by rote, but did not 
succeed in conversing at all. 

Note : This autosuggestion was given to test the possi- 
bility of reviving a long-forgotten language during the 
semi-conscious state produced by the drug. It was sug- 
gested by the fact that two of the patients previously 
examined had spoken their childhood language after be- 
coming unable to speak English. This autosuggestion 
brought out very little more Chinese than could otherwise 
have been spoken by this individual. In fact, the uncon- 
scious utterances throughout the whole experiment were, 
with perhaps one exception, based on recent objective 
experiences. 

/ remember the departure of Mrs. G. and Mrs. H. and 

176 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

my amazement at their going so soon. I thought they had 
just come. Was bewildered when they told me it was 6 :00 
o'clock. I thought surely it was not more than 4:30. 
When Dr. Y. and Mrs. B. went I came to consciousness 
suddenly and was again amazed and incredulous when 
they told me it was 9 :00 o'clock, as I thought it was still 
4:30. 

Note: This total unconsciousness of the lapse of time 
is in striking contrast to this individual's habitual and care- 
fully cultivated ability to estimate how long she has slept, 
during natural sleep. 

My other memories of this interval before Dr. Y. went 
are vivid but fragmentary. I have no idea in what order 
they occurred. The flashes of consciousness included a 
fully normal breadth of mental content, minus only the 
sense of the passage of time. I note them in the order in 
which they occur to me. 

(a) / remember seeing and hearing a flashlight, and 
thinking, "Is it possible they are trying to take a photo- 
graph in such a crowded room?" (Note: Actual time, 
7:45 p.m.) 

(b) / remember Dr. Y. feeding me some cylindrical 
scraps of white medicine on the tip of a spoon. It tasted 
slightly metallic, but I reasoned that the scopolamine might 
have caused a bad tasting mouth. I did not dream that 

177 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

the medicine was quinine. (Note : Time, about 7 :40 p. m.) 

(c) / remember one long, keen scratch on the sole of 
my foot. The sensation was such that I inferred it was 
done with the point of a long, black hatpin. Without 
looking to see if this imagination was correct, I said, 
"Ouch, that hurts/' and thought, "What rotten technique 
to test Babinski with a hatpin!" then instantly went to 
sleep again. (Note: Time, 5:30.) 

(d) / remember standing by the bureau combing my 
hair, with Miss T. steadying me. I was staggering and 
somewhat afraid of falling, but was greatly amused by the 
resemblance to inebriety. I have been told since that I 
combed my hair twice, but I remember only once. I do 
not remember going to the bureau, nor going back to bed 
again. (Note: Time, about 9:15.) 

(e) / remember once trying hard to get up to go to 
the railroad station, while Dr. V . H. and two other people 
prevented me. I could not understand why they would not 
let me go. (Note: Time, about 7:40.) 

(f) / remember the spider on the ceiling distinctly, 
was not afraid of it, but was amazed that the nurses did 
not bring a broom and sweep it down. Part of the time 
there were two spiders of equal size about one foot apart. 
They not only moved from side to side on the ceiling, but 
seemed to spin down on a thread about a foot from the 

178 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

ceiling, then to fall about half an inch, then climb up the 
thread to the ceiling again. I found it hard to believe that 
these were merely the stub of one lead pipe. (Note: 
Time, about 8:25.) 

(g) / remember at one time I could not see a whole 
face, but only one feature at a time. I recognized Dr. 
V. H. y s mouth in the midst of a dark blur. (Note: Time, 
about 7:30.) 

(h) The only really distressing part of the whole 
experience was when I repeatedly found my fingers or 
elbow sticking into people's eyes. The eyes seemed quite 
detached features except when I accidentally touched them. 
(Note: Time, about 6:40, and again at 7:45.) 

My next memory is of waking as refreshed as if it were 
morning, and wholly conscious of my surroundings. I was 
alone with Miss T. and she said it was 10:30 p. m., but I 
kept involuntarily saying "yesterday" for the preceding 
events, and "this morning" for the present. Dr. V . H. and 
Dr. S. came in, and talked to us, and I thought of many 
interesting things to say, but was constantly interrupted in 
the midst of a sentence by inability to remember what I 
was talking about. When given a cue word I could usually 
finish the sentence, if it were not too long; otherwise I got 
of the track again and had to be given another cue before 

179 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

/ could go on. Each moment's mental content was complete 
and rational, but faded as if "writ in water" 

In order to analyze or even to observe accurately such 
complex phenomena as these, one should be not only an 
experienced clinical psychologist, but should be deeply 
versed in the psychology of dreams, of somnambulism, of 
inebriety, of autosuggestion; of paralogia, aphasia, alexia, 
and agraphia; of apraxia, astasia and abasia; of illusions, of 
fixed ideas, of flight of ideas; and especially of the many 
different kinds of memory, including the typical psychopathic 
forms of partial amnesia, in which one kind of memory is 
lost while other kinds of memory are unimpaired. 

Moreover, this psychological insight should be combined 
with an intimate knowledge of what is at present known 
concerning the central nervous system — with the ability to 
classify functional abilities and disabilities according to the 
anatomical area or path probably involved, whether spinal, 
medullar, cerebellar, thalamic, or cortical, and the chief 
cortical localizations. 

The technique of testing should be of clinical simplicity 
and practicality, but should be applied with laboratory 
accuracy, otherwise the labor will be worse than useless, 
it will be in danger of leading to false results. 
Suggested Problems for Study 

1. What is the simplest possible technique which will 

180 



SCOPQLAMINE-MORPHINE ANAESTHESIA 

adequately test reflexes, and the briefest and most con- 
venient method of recording the same? 

2. What is the simplest adequate technique for testing 
and recording mental phenomena? 

3. Which parts of the nervous system are affected, and 
in what order? 

4. When questions are answered irrelevantly, is it from 
inattention, or auditory aphasia, or inability to remember 
the question, or preoccupation with preconceived ideas, or 
is the correct idea perhaps in mind but its expression pre- 
vented by motor aphasia? 

5. What are the effects of voluntary autosuggestion 
and of conscious expectation of what may happen during 
anaesthesia, and what are the limitations of these effects? 

6. What are the effects of involuntary or subconscious 
autosuggestion — of deep seated fears, worries, and inhibi- 
tions — and how may these be kept from interfering with 
successful analgesia? Could some mild and expurgated 
form of Freudian psychanalysis beforehand prevent some 
of the occasional cases of excitement and resistance during 
the "twilight" condition, and thus obviate the necessity of 
supplementing the treatment with chloroform or ether? 

7. What is the progressive effect of the treatment on 
reaction-time to auditory, visual and tactual stimuli? In 
what order do sensory disturbances appear? To what 

181 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

degree are these disturbances of cortical origin and to 
what degree are they caused by changes in the end-organs 
of sensation? 

8. When is the beginning and what is the order and 
rate of progress of motor inco-ordination in different 
muscle groups? Are the large fundamental or the finer 
accessory muscles first affected? 

9. To what degree is indistinct articulation due to a 
stiffening or thickening or dryness of the muscles of speech, 
or is this phenomenon caused wholly by disturbance in the 
nervous apparatus for the control of these muscles? 

10. Are optical illusions during this treatment caused 
wholly by the functional disturbances in the eye muscles, 
or are they partly ideational? To what extent are they 
influenced by past experience? To what degree are they 
based on actual objective stimulus, and to what degree do 
they consist of associated phantasies? Do they come dur- 
ing a stage of rather active ideation, or during the stage 
when the field of vision is narrowed and the ideas are few? 

11. Are there areas of unequally diminished sensation 
on the skin, as there are in the deeper structures? If so, 
do these correspond with the distribution of endings from 
certain nerves, or are they more like the areas of sensory 
disturbance sometimes found in hysterical cases? 

12. If silence does not always prove unconsciousness, 

182 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

and active intelligent speech does not always register itself 
in the cortex, even deeply enough to be remembered a 
moment later, what shall be accepted by investigators as an 
adequate test of consciousness? If the taste of raw quinine 
is described as "about as bitter as horehound candy" and 
if a mother at the moment of childbirth asks calmly, "What 
is that funny feeling?" what shall be considered an effect- 
ive degree of sensory consciousness? 

In conclusion, I wish to express the most sincere thanks 
to those without whose co-operation this study could not 
have been made. The taking of reflexes was done by Drs. 
Conn, Kacin, Gardner, and McCann of the Mary Thomp- 
son Hospital; the psychological tests on myself during the 
experimental anaesthesia were given by Miss Ada Town- 
send of Northwestern University; the tests of sensation 
were given me by Dr. Josephine Young of Rush Medical 
College; the recording of my reactions was done by Mrs. 
Leila Love Brown, who was private secretary to a three 
years' scientific expedition around the world; the experi- 
ments on my ability to speak my childhood's language were 
given by Mrs. Samuel B. Groves, formerly of Tungchow, 
China. 

Finally, it should be understood that all the phenomena 
here recorded occurred in connection with the dosage pre- 
scribed by Dr. Bertha Van Hoosen, which is so different 

183 



SCOPOLAMINE-MORPHINE ANAESTHESIA 

from that used at Freiburg that quite different results may 
be recorded by experimenters who study the mental effects 
of the original Freiburg method. 

I believe that not only Dr. Van Hoosen but everyone else 
concerned in this study has conscientiously refrained from 
drawing any dogmatic conclusions from the insufficient data 
so far collected. 

The mental phenomena observed have proved more com- 
plex than a study of the medical literature of the subject 
had given us any reason to expect. Hence this report is 
offered as a contribution to the technology of determining 
individual variations under the treatment. It aims to sug- 
gest a means of increasing alertness and accuracy of observa- 
tion relative to mental phenomena, and to influence as many 
observers as possible to adopt a uniform technique. 



184 



BIBLIOGRAPHY 

Compiled from the Crerar Library 

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Jour., N. Y., 1906, xix, 47-49. 
Status of Scopolamine-Morphine Anaesthesia. Jour. Am. Med. 

Assn., Chicago, 1907, xlviii, 344. 
de Almeida, D. — A Anesthesia pela scopolamina. Rev. med. 

cirurg. do Brazil Rio de Jan., 1905, xiii, 249-256. 
Anderson, W. — Notes on Scopolamin-Morphin Surgical Anaesthesia. 

Pacific Med. Jour., San Fran., 1905, xlviii, 727-729. 
Arce, J. — El Empleo de la escopolamina en cirurgia. Rev. Soc. mid. 

arg., Buenos Aires, 1905, xiii, 127-143. 
Avarff'y, F. — Scopolamin-Morphium bodulat a Sziileszetben. 

Orvosi hetil, Budapest, 1908, lii, 702-708. 
Avellis. — Laryngotomie ohne kaniile und ohne Chloroform in der 

Scopolamin-Morphiumnarkose. Verhandl. d. Ver. siiddeutsch. 

Laryngol., Wiirzb., 1907, 350-352. 
Babcock, W. W. — A New Method of Surgical Anaesthesia. Proc. 

Phila. Co. Med. Soc, Phila., 1905-6, xxvi, 347-357. 
Bardet, G. — Sur le dosage de la scopolamine dangers, presentes par 

cette drogue. Bull. gen. de therap., etc., Paris, 1905, CI. 

622-627. 
Nouvelle contribution a l'etude de la scopolamine. Ibid., 1907, 

cliv, 581-588. 
Bass, O. — Hundertundsieben Geburten in Skopolamin-Morphin 

Halbnarkose. Miinchen. med. Wchnschr., 1907, liv, 519-524. 
Beer, Carl. — Die Verwendung des Skopolamin-Morphiums als 

alleiniges und als vorbereitendes Narkotikum, Freiburg, i B., 

1910. Speyer und Kaerner, 47 P-8°. 

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BIBLIOGRAPHY 

Berlillon. — Des Anesthesiques et en particulier de la scopolamine, 

envisages comme adjuvants a la suggestion hypnotique. Rev. de 

Vhypnot. et psychol. physiol., Paris, 1905-6, xx, 307. 
Also: Jour, de neurol., Paris, 1906, xi, 13-15. 
Bernardini, D. — Suir applicazione della anestesia Morfino-Scopola- 

minica nel cane. Clin. Vet., Milano, 1907, xxx, sez. scient., 

2; 97. 
Bertino, A. — Suir uso della Scopolamina come analgesico nelle 

partorienti. Ginecologia Firenze, 1907, iv, 609-623. 
Berutti, J. A. — Weitere 600 Geburten im Skopolamin-Dammer- 

schlaf. Med. Klin., 1909, v, 497-500. 
Bjorkenheim, E. A. — Ueber die Anwendung des Skopolamin- 

Morphiums bei Operationen und Entbindungen. Prakt. 

Ergeb. d. Geburtsch. u. Gyndk., Wiesb., 1910, ii, 1-66. 
Blisnisansky, G. — Ueber den Angeblichen nachteiligen Einfluss des 

Skopolamens auf Puis und Temp. Zentralbl. f. Gyndk., 1909, 

xxxiii, 301-306. 
Bloch, E. — La narcose Scopolaminique en Oto-Chirurgia. Presse 

oto-laryngol. beige, Brux., 1903, ii, 625-636. 
Zur Skopolaminnarkose in der Ohrchirurgie. Beitr. z. Ohrenh. 

Festschr., Berlin, 1905, 129-140. 
Blos, E. — Ueber die Schneiderlini'sche Skopolamin-Morphium- 

narkose. Aerztl. Mitth. a. Baden., Karlsruhe, 1902, lvi, 281- 

284. 
Boesch, E. — Die Wertigkeit des Skopolamin-Morphium in der 

Gynsekologie. Zentralbl. f. Gyndk., 1908, xxxii, 1580-1584. 
Bokenham, T. J. — Scopolamine, Therap. Gaz. Detroit, 1894, 3 s, 

x, 652-654. 

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Bonheim. — Ueber 70 Morphium-Skopolamlnnarkosen. Deutsche 

med. Wchnschr., Berlin, 1904, xxx, 1113. 
Bonner, K. P. — Scopolamine: Its Origin, Uses and Therapy. 

Carolina Med. Jour., Charlotte, 1907, lvi, 872-878. 
Bosse, B., and Eliasberg, W. — Der Dammerschlaf oder die Skopol- 

amin-Morphin-Mischnarkose in ihrer Anwendung bei Entbin- 

dungen und Operationen. Samml. klin. Vortr., 1910, n. F., 

No. 599-601. Gynak., No. 215-217; 547-649. 
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